RECORDS OF INTER-HOSPITAL TRANSFER OF PERSON IN CRITICAL SITUATION

• DOI: 10.22533/at.ed.1593862317102

• Palavras-chave: Nursing; Specialist Nurse; Person in Critical Situation; Nursing Records; Emergency Service.

• Keywords: Nursing; Specialist Nurse; Person in Critical Situation; Nursing Records; Emergency Service.

• Abstract:

  Inter-hospital transfers (ITH) are procedures that require prior preparation by nurses to ensure safety during the process. In order to prevent the risk associated with transfers, institutions must implement a specific transfer plan, with an efficient system of material, human and documentation resources. Nursing records (RE) must reflect the nurse's critical thinking, describe the problems that the user presents, the nursing interventions carried out and the results achieved sensitive to nursing interventions.
  A continuous quality improvement project was developed through action research methodology, with the objectives of analyzing nursing records relating to HIT of people in critical situations; implement strategies to improve the records analyzed and evaluate nurses' satisfaction with the interventions implemented. 
  A “check-list” was used to verify data recorded in the clinical files of users undergoing HIT. A “standard” record, pre-structured and editable in the computer program used, was made available to nurses in a medical-surgical emergency service in Portugal. After implementing the interventions, an electronic questionnaire was administered to nurses to assess their satisfaction with the process.
  The content of the RE of transferred users was evaluated, and it was possible to verify the existence of omission/lack of information on the preparation of inter-hospital transfers in the RE. The reasons associated with this non-existence are associated with issues of time management and poor prioritization of care by nurses. After implementing the interventions, the nurses evaluated them as positive and reported being satisfied with them.
  Overcrowding in emergency services due to a large influx associated with a lack of human resources, the need to develop skills such as time management, can lead to inadequate documentation of care.