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A Importância Das Anotações De Enfermagem Em Prontuários De Pacientes Hospitalizados Segundo A Equipe De Enfermagem.

Introduction: Introduction: Nursing annotation is an indicator that assists the quality of care provided, when there is the presence of a low rate of complete completion, it is able to represent the continuity of care and the legitimacy of nursing team work. Objective: To understand and describe the importance of nursing in the hospitalized patient's medical records according to the reports of the nursing staff. Methods: This is a qualitative, non-experimental, descriptive cross-sectional exploratory study conducted through semi-structured interviews with nursing professionals from a hospital in the interior of Sao Paulo. Data collection was performed through an interview organized by the Content Analysis technique, according to Bardin. Results: Fifteen nursing professionals participated in the study. Interview analysis in three categories: Care notes as care for the nursing staff about patient care and evolution; Moments to take as nursing notes; Difficulty making nursing notes. Conclusion: The research consisted of the presence of nursing notes in medical records of hospitalized patients after the nursing dispensation.