AUDIT IN NURSING: AN ANALYSIS OF RECORDS OF CARE OFFERED FOR HIGH RISK PREGNANT WOMEN

Abstract

Analyze the records of nursing care provided to pregnant women at high risk, considering the customers hypertensive at the Hospital Universitario Antonio Pedro, by checking the records relating to the provision of care contained in medical records.This is an exploratory-descriptive and quantitative, analyzing records of the care provided to pregnant women with hypertension at the maternity of a university hospital, from the retrospective audit. Data were organized according to the records of the individual treatment plan (ITP) and nursing evolution, evidencing a reference to the interrelationship of nursing care, with actions recommended by the Ministry of Health analysis shows that the records had flaws, necessitating intervention and support measures, where nurses discuss the necessary adjustments, since in only 42% of shifts, had completed an ITP, although the evolution of nursing is at 83%. Of the ten items analyzed in evolution, only three are present, which represents a parameter unsatisfactory. There should also be discussions of alternatives to ensure continuity of care, being based on ethical and legal principles, contributing to security professionals, offering visibility to the work that the team is playing.