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AUDITING THE QUALITY OF NURSING CARE THROUGH
HOSPITAL RECORDS
Adna Borges dos Santos1
Juliana Magalhães Bernardino2
Cristiane Borba Souto Rosendo3
Gilma Oliveira e Silva4
Gilnar Oliveira e Silva5
Kheyla Santos Nascimento6
Maria Tereza Figueiredo de Rezende7
Silvania Maria de Santana Souza8
Stella Ferreira da Costa9
Abstract: The quality and completeness of nursing records are fundamental for traceability of care,
patient safety, and care management. This study aimed to analyze the quality of nursing records
in the medical records of patients hospitalized in a university hospital in Northeast Brazil, through
a retrospective audit. This is a descriptive, cross-sectional, quantitative, and documentary study,
carried out based on the audit of 151 medical records of patients hospitalized in 11 clinical-surgical
units, between December 2022 and February 2023. Data collection was carried out between June
2024 and December 2025 by nurses from the Nursing Division, using a structured instrument. Data
1 Graduada em Enfermagem, Especialista em Saúde Pública
2 Mestre em Gestão e Economia da Saúde Graduada em Enfermagem
3 Graduada em Enfermagem
4 Graduada em Enfermagem, especialista em Saúde Pública
5 Graduada em Enfermagem, Especialista em Gestão Pública
6 Mestre em Gestão e Economia da Saúde, Graduada em Enfermagem
7 Graduação em Enfermagem
8 Graduada em Enfermagem, Especialista em Nefrologia
9 Graduada em fonoaudiologia, Especialista em Saúde e Segurança do trabalho
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were analyzed using descriptive statistics and the McNemar test for paired comparison of record
completeness between the fi rst and fourth day of hospitalization. Low quality nursing notes were
identifi ed, classifi ed as fair in 47.0% and poor in 46.4% of the medical records, as well as vital sign
records, classifi ed as fair in 60.9% and poor in 31.1%. Although nursing progress notes were present
in 95.4% of the medical records, nursing diagnosis (9.9%), implementation (4.6%), and nursing
evaluation (4.6%) were poorly documented, highlighting weaknesses in the continuity of the Nursing
Process. The completeness of daily progress notes decreased from 74.2% on the fi rst day to 46.4% on
the fourth day of hospitalization (p < 0.001). Gaps were also observed in the application of risk scales,
especially the Fugulin Scale, absent in 84.1% of the medical records, followed by the Morse (30.5%)
and Braden (27.8%) scales. The fi ndings reveal a pattern of documentary fragility that intensifi es
throughout hospitalization, compromising the traceability of care, patient safety, and support for
decisions related to care and workforce sizing. Strengthening continuing education is recommended,
especially during periods of higher risk of under-documentation, coupled with systematic monitoring
of quality indicators through periodic audits. These measures can contribute to improving nursing
documentation and supporting the management of care in hospital institutions.
Keywords: Nursing Audit. Quality of Healthcare. Nursing Process.
INTRODUCTION
Nursing records are the main instrument through which the Nursing Process becomes
visible, verifi able and subject to evaluation, documenting the stages of care provided and translating,
in technical language, the clinical reasoning and professional judgment of the nurse. Inserted in the
patient’s medical record, the main instrument of communication among the professionals who are
part of the health team, with legal, care, administrative and teaching and research purposes, these
records constitute a primary source of information for the continuity of care, for auditing and for
the evaluation of the quality of care provided, so that their documentary quality works, in the fi nal
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analysis, as an indirect indicator of the quality of nursing care itself. Studies on auditing nursing
records indicate that, although documentation is sometimes criticized for evaluating the record and
not directly evaluating the care provided, there is a positive correlation between the quality of records
and the quality of nursing care, which justifi es the audit of medical records as a strategy for indirect
evaluation of care (SETZ; D’INNOCENZO, 2009).
In Brazil, the registration of professional nursing actions is regulated by the Federal Nursing
Council (COFEN), which, through COFEN Resolution No. 429/2012, provides for the registration of
professional actions in the patient’s medical record and in other nursing documents, regardless of the
means of support, traditional or electronic (COFEN, 2012). At the same time, the Systematization of
Nursing Care (NCS) organizes professional work in terms of method, personnel and instruments,
making it possible to operationalize the Nursing Process (BARROS; LOPES, 2010). During the period
to which the records analyzed in this study refer, the NCS and the Nursing Process were regulated
by COFEN Resolution No. 358/2009, which organized the Nursing Process into fi ve interrelated,
interdependent, and recurrent stages: data collection (or nursing history), nursing diagnosis, nursing
planning, implementation, and nursing evaluation (COFEN, 2009). This resolution was later revoked
by COFEN Resolution No. 736/2024, which updated the regulation and redefi ned the stages of the
Nursing Process as evaluation, diagnosis, planning, implementation, and evolution, without changing
the requirement for systematic and deliberate documentation of care in all environments in which
professional nursing practice occurs (COFEN, 2024a).
The quality of nursing records has direct implications for patient safety. The Ministry of
Health instituted, through Ordinance No. 529/2013, the National Patient Safety Program (PNSP),
structured based on six international safety goals that include, among others, the correct identifi cation
of the patient, the improvement of communication between health professionals, and the reduction
of the risk of falls and pressure injuries (BRASIL, 2013). The institution of this program resulted,
among other factors, from the recognition that Brazil lacked systematic mechanisms for reporting and
monitoring care incidents, many of which were associated with communication and recording failures
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among health professionals (CAPUCHO; CASSIANI, 2013). Nursing documentation constitutes the
informational support that evidences the fulfi llment of these goals, so that incomplete or low-quality
records compromise the traceability of care and hinder the early identifi cation of care risks. In this
sense, risk assessment instruments widely used in Brazilian hospital nursing practice, such as the
Braden Scale for pressure injury risk, adapted and validated for Portuguese by Paranhos and Santos
(1999), the Morse Scale for fall risk, developed by Morse (2009), and the Fugulin Scale for classifying
the degree of dependence of patients in relation to nursing care, developed by Fugulin, Gaidzinski and
Kurcgant (2005), depend on the systematic recording of their scores and classifi cations so that they
fulfi ll their function of supporting clinical and managerial decisions.
The Fugulin Scale, specifi cally, in addition to its function in identifying care risks, constitutes
the technical basis for the dimensioning of the nursing staff (FUGULIN; GAIDZINSKI; KURCGANT,
2005), currently regulated by COFEN Resolution No. 743/2024 and Normative Opinion No. 1/2024/
COFEN, which establish minimum parameters of nursing hours per patient according to the degree
of dependence identifi ed by the Patient Classifi cation System (COFEN, 2024b, 2024c). The absence
of systematic recording of this scale, therefore, not only compromises individual care, but also the
institution’s ability to technically support the planning of the nursing workforce.
Nursing auditing, understood as the systematic and critical analysis of the records produced by
the nursing team, is recognized in the national literature as a relevant tool for identifying documentary
weaknesses and proposing strategies for continuous improvement of care quality (LOPES; ASCARI,
2016). Brazilian studies conducted in teaching hospitals and public hospitals in different regions of
the country have repeatedly shown weaknesses in the completeness of nursing records, especially
in the stages that are more dependent on nurses’ clinical reasoning, such as nursing diagnosis and
assessment, even though the evolution stage, which is more descriptive, has a higher frequency of
completion (SETZ; D’INNOCENZO, 2009; SILVA et al., 2019; DODO et al., 2020). A more recent
study, conducted in a large hospital in the Midwest region, reinforced this panorama by identifying
low quality scores for all dimensions of the Nursing Process: diagnosis, interventions, and outcomes,
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with statistically signifi cant variation between the different inpatient units of the same institution
(PIMENTEL et al., 2023), which suggests that document fragility does not result only from individual
factors of professionals, but also from specifi c organizational determinants of each care unit. These
fi ndings reinforce the need for periodic audits as an instrument for managing the quality of care
in teaching hospitals, particularly those linked to the network of Federal University Hospitals, in
which the quality of documentation is also relevant for teaching, research, and hospital accreditation
processes.
In view of this scenario, the present study aimed to analyze the quality of nursing records in
the medical records of patients hospitalized in a university hospital in the Northeast of Brazil, through
a structured retrospective audit, characterizing the completeness and quality of nursing notes, vital
signs records, risk assessment instruments and stages of the Nursing Process, in order to support the
management of care quality and the prioritization of continuing education strategies in the institution
studied.
METHOD
Study design and setting
This is a descriptive, cross-sectional, quantitative study, with a documentary design, carried
out from a retrospective audit of medical records of patients hospitalized in a federal university
hospital in the Northeast of Brazil, which is part of the Federal University Hospitals Network. The
study was conducted within the scope of the institution’s nursing care quality management, as part of
the activities of monitoring quality indicators of nursing records conducted by the Nursing Division.
Population, sample and collection period
The study population consisted of medical records of patients hospitalized in eleven clinical-
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surgical hospitalization units of the institution, identifi ed in this study by alphanumeric coding (Unit
1 to Unit 11) in order to preserve the identifi cation of care units, referring to hospitalizations with
admission date concentrated between December 2022 and February 2023. The analyzed sample
corresponded to 151 different medical records; data collection was carried out between the years
2024 and 2025, treated in this study as a single cross-sectional sample, since all records refer to the
same universe of hospitalizations that occurred between December 2022 and February 2023 and
were collected with the same structured instrument, with no change in criteria between the collection
periods.
Instrument and variables analyzed
Data were collected using a structured electronic instrument, applied to each audited
medical record. Information regarding the hospitalization sector, admission and discharge dates, and
identifi cation of the nurse responsible for the record were evaluated. Nursing evolution was analyzed
in the fi rst four days of hospitalization (1st to 4th IHL), considering eight systemic domains: general,
neurological, respiratory, circulatory, digestive, nutritional, genitourinary, and locomotor status. In
addition to complementary aspects, such as length of hospitalization, eliminations, catheterizations,
probes, drains, care performed, prescribed conducts, new problems identifi ed, and application of
scales.
The quality of dressing records, nursing notes and vital signs were also evaluated, classifi ed
as good, regular, poor, not evaluated or not applicable, according to the item. Risk classifi cation was
verifi ed using the Braden, Morse and Fugulin Scales. In addition, checklists were used to verify the
presence of the components of the Nursing Process: evolution, diagnosis, planning, implementation
and evaluation, as well as records related to precautions and patient safety, intra- and intersectoral
transfers and referrals. The instrument also included the verifi cation of records of venous access, fl uid
control, dressings and nursing discharge.
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Data analysis
The data were exported to an electronic spreadsheet and processed and analyzed in a Python
programming environment, with descriptive statistics. Categorical variables were expressed in
absolute and relative frequencies. The variable length of hospital stay was calculated by the difference
between the dates of admission and discharge and expressed as mean, standard deviation, median,
and interquartile range. For the multiple-choice variables (checklists), the frequency of each item
was calculated in relation to the total of 151 audit records, assuming that the same medical record
could present more than one item simultaneously. To analyze the completeness of the daily nursing
evolutions, the mean number of items recorded per evolution and the proportion of evolutions in
which the eight systemic domains evaluated were fully documented were calculated for each of the
four days of hospitalization analyzed; additionally, to test whether the variation in completeness
between the fi rst and fourth days of hospitalization (same sampling unit, measured at two moments)
was statistically signifi cant, the McNemar test was applied for categorical paired data, with continuity
correction and calculation of the exact p-value, adopting a signifi cance level of 5% (α = 0.05). During
the data consistency check, a typing inconsistency was identifi ed in one of the 151 records (discharge
date prior to the date of admission), which was excluded exclusively from the calculation of the length
of hospital stay, being maintained in the other analyses, as it did not compromise the other variables;
this inconsistency is discussed as a limitation of the study.
Ethical aspects
The study was conducted based on data from medical records audited already collected
within the scope of the institution’s nursing care quality management, with the purpose of internal
monitoring of care indicators, under the authorization and supervision of the Nursing Division. The
data were treated in aggregate and anonymized form for the purposes of this analysis, without nominal
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identifi cation of patients or care professionals in the results presented. The project was submitted to
and approved by the Research Ethics Committee of the institution, in accordance with the Resolution
of the National Health Council No. 466/2012 and its complementary Opinions, under Consolidated
Opinion No. 5.047.322 and CAAE No. 51228621.2.0000.8807.
RESU LTS
Sample characterization
A total of 151 records from the medical records of patients hospitalized between December
2022 and February 2023 were analyzed, distributed in eleven clinical-surgical hospitalization units,
identifi ed in this study by alphanumeric coding (Unit 1 to Unit 11) to preserve the identifi cation of the
care units. Unit 1 concentrated the largest number of audited records (22; 14.6%), followed by Units 2
(20; 13.2%) and 3 (19; 12.6%); the other units had between 8 and 17 records each (Table 1).
The length of hospital stay, calculated based on the dates of admission and discharge in the
medical records, had a median of 3 days (interquartile range: 2 to 3.75 days) and a mean of 4.46 days
(standard deviation of 5.20 days), ranging from 1 to 35 days, calculated on 150 of the 151 records; one
record was excluded from this analysis because it had a discharge date prior to the date of admission,
a typing inconsistency discussed in the limitations section of the study.
Table 1 – Distribution of audit records according to detention unit
Inpatient unit n%
Unit 1 22 14,6
Unit 2 20 13,2
Unit 3 19 12,6
Unit 4 17 11,3
Unit 5 14 9,3
Unit 6 13 8,6
Unit 7 11 7,3
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Unit 8 10 6,6
Unit 9 96,0
Unit 10 85,3
Unit 11 85,3
Source: prepared by the authors (2026).
Quality of dressing records, nursing notes and vital signs
Nursing records were classifi ed as regular in 71 medical records (47.0%) and poor in 70
(46.4%), with only 10 (6.6%) classifi ed as good; that is, 93.4% of the audited medical records presented
nursing records with quality below what was considered adequate by the audit instrument. The
recording of vital signs showed a similar pattern, with 60.9% of the records classifi ed as regular
and 31.1% as poor, totaling 92.0% of records not fully adequate, and only 7.9% classifi ed as good.
Regarding dressing records, 74 of the 151 medical records (49.0%) had an indication for an applicable
dressing; among these, 59 (79.7% of the applicable tests) were classifi ed as poor, 12 (16.2%) as regular
and only 3 (4.1%) as good, constituting the item with the worst relative performance among those
evaluated when considering exclusively the cases in which the item was pertinent to the patient’s
clinical condition (Table 2).
Table 2 – Classifi cation quality attributed to dressing records, nursing notes and vital signs records
Rated Item Category n%
Dressing Records Bad 59 39,1
Regular 12 7,9
Good 3 2,0
Not applicable 77 51,0
Nursing notes Bad 70 46,4
Regular 71 47,0
Good 10 6,6
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Vital signs recording Bad 47 31,1
Regular 92 60,9
Good 12 7,9
Source: prepared by the authors (2026).
Registration of risk assessment scales
The registration of the risk assessment scales presented the most critical standard among
the items audited. The Fugulin Scale, used to classify the degree of dependence of the patient in
relation to nursing care and the technical basis of personnel sizing, was not recorded in 127 of the 151
medical records (84.1%); among the medical records recorded, 18 (11.9% of the total) were classifi ed
as minimum care, 5 (3.3%) as intermediate care, and only 1 (0.7%) as high dependence. The Morse
Scale, used to assess the risk of falls, was not recorded in 46 medical records (30.5%); among those
evaluated, 48 (31.8%) were classifi ed as non-risk, 42 (27.8%) as moderate risk, and 15 (9.9%) as high
risk. The Braden Scale, used to assess the risk of pressure ulcers, had the lowest proportion of no
records among the three scales, although it was signifi cant: 42 medical records (27.8%) did not have
a recorded classifi cation; among those evaluated, 92 (60.9%) were classifi ed as low risk, 13 (8.6%) as
moderate risk and 4 (2.6%) as high risk (Table 3).
Table 3 – Risk classifi cation recorded on the Braden, Morse and Fugulin Scales
Scale Category n%
Braden (pressure injury risk) Not rated 42 27,8
Low risk (>17) 92 60,9
Moderate risk (13–16) 13 8,6
High risk (<12) 42,6
Morse (risk of falling) Not rated 46 30,5
Risk-free (0–24) 48 31,8
Moderate risk (25–44) 42 27,8
High risk (>45) 15 9,9
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Fugulin (degree of dependence) Not rated 127 84,1
Minimal care (12–17) 18 11,9
Intermediate Care (18–22) 53,3
High dependency (23–28) 10,7
Source: prepared by the authors (2026).
Recording of the stages of the Nursing Process
Regarding the stages of the Nursing Process identifi ed in the audit checklist, nursing evolution
was the most frequently present item, appearing in 144 of the 151 medical records (95.4%). Nursing
planning was identifi ed in 93 medical records (61.6%). The other stages, which were more dependent
on the nurse’s clinical reasoning, had a substantially lower frequency: the nursing diagnosis was
included in only 15 medical records (9.9%), implementation in 7 (4.6%) and nursing evaluation in 7
(4.6%). In 6 medical records (4.0%), none of the items of the Nursing Process were present (Table 4).
Table 4 – Nursing Process Items identifi ed in the audit checklist
Item n%
Evolution of nursing 144 95,4
Nursing planning 93 61,6
Nursing diagnosis 15 9,9
Nursing Implementation 74,6
Nursing evaluation 74,6
No record of any items 6 4,0
Source: prepared by the authors (2026).
Note: percentages do not add up to 100% because each medical record can present more than one
item.
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Precautionary items, patient safety, transfer, and general checklist
Among the items related to precautions and patient safety, the registration of the identifi cation
bracelet was the most frequent (125; 82.8%), followed by the registered controls (94; 62.3%). The
recording of vital signs in all shifts was present in 66 medical records (43.7%) and the recording
of nursing notes in all shifts in only 41 (27.2%); infection prevention measures were included in 23
medical records (15.2%). Regarding the record of transfer or referral, 48 medical records (31.8%) did
not have any record of the item, even though the transfer was pertinent to the case, which represents
the largest proportional gap between the checklists analyzed. In the general checklist, the record of
venous access (103; 68.2%) and fl uid control (97; 64.2%) were the most frequent items, while the
record of dressings (34; 22.5%) and, above all, the record of nursing discharge by the nurse (54; 35.8%)
or by the nursing technician/assistant (42; 27.8%), showed reduced frequency; in 15 medical records
(9.9%) no item from the general checklist was present (Table 5).
Table 5 – Precautionary and patient safety items, transfer log, and general checklist identifi ed in the
audit checklist
Item n%
Precautions and patient safety
ID Wristband Registration 125 82,8
Registered controls 94 62,3
Vital signs in all shifts 66 43,7
Nursing notes on all shifts 41 27,2
Infection prevention measures 23 15,2
No record of any items 7 4,6
Transfer Logging/Forwarding
No registration (where applicable) 48 31,8
Readmission to the operating room 44 29,1
Not applicable 39 25,8
Referral to the operating room 26 17,2
Intersectoral referral (exams/consultations/transfer) 20 13,2
General checklist
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Venous access logging 103 68,2
Water control 97 64,2
Nurse discharge record 54 35,8
Registration of discharge by the technician/assistant 42 27,8
Dressing registration 34 22,5
No record of any items 15 9,9
Source: prepared by the authors (2026).
Note: percentages do not add up to 100% within each group because each medical record may have
more than one item.
Completeness of nursing evolution over the fi rst four days of hospitalization
The analysis of the completeness of the content of the nursing outcomes recorded in the fi rst
four days of hospitalization (1st to 4th IHL) showed a progressive decline in both the presence and
completeness of the records over the days of hospitalization. On the fi rst day, 9 medical records (6.0%)
did not show any recorded evolution, a proportion that increased to 11 (7.3%) on the second day, 32
(21.2%) on the third day and 66 (43.7%) on the fourth day. The mean number of items documented by
evolution followed this downward trend, from 9.68 items (standard deviation of 3.62) on the fi rst day to
5.95 items (standard deviation of 5.61) on the fourth day. Consequently, the proportion of evolutions in
which the eight systemic domains evaluated (general, neurological, respiratory, circulatory, digestive,
nutritional, genitourinary, and locomotor status) were fully documented fell from 74.2% on the fi rst
day to 46.4% on the fourth day (Table 6). Of the total of 151 medical records, 55 (36.4%) presented
completeness on the fi rst day that was not repeated on the fourth day, whereas only 13 (8.6%) presented
the inverse pattern (incomplete on the fi rst day and complete on the fourth); this asymmetry was
tested by the McNemar test for paired data, which confi rmed that this was a statistically signifi cant
difference, and not a random variation (χ² with continuity correction = 24.72; p < 0.001). Of the total
number of medical records audited, 78 (51.7%) had recorded evolution on all four days evaluated, and
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only 3 medical records (2.0%) had no evolution recorded on the four days analyzed.
Table 6 – Completeness of nursing evolution from the 1st to the 4th day of hospitalization (IHL) (n =
151)
Day of hospitalization Missing developments n (%) Average Registered
Items (SD)
Developments with the 8
full domains n (%)
1st IHL 9 (6,0%) 9,68 (3,62) 112 (74,2%)
2nd IHL 11 (7,3%) 10,13 (3,84) 117 (77,5%)
3rd IHL 32 (21,2%) 8,61 (5,05) 104 (68,9%)
4th IHL 66 (43,7%) 5,95 (5,61) 70 (46,4%)
Source: prepared by the authors (2026).
Note: the difference in completeness between the 1st and 4th IHL was statistically signifi cant
(McNemar’s test, χ² = 24.72; p < 0.001).
DISCUSSION
The fi ndings of this audit show that the quality of nursing records in the university hospital
studied presented relevant weaknesses, converging with what the national literature has repeatedly
described in retrospective audits of medical records carried out in Brazilian hospitals, including in more
recent publications. The study by Setz and D’Innocenzo (2009), carried out in a university hospital
in São Paulo, identifi ed that 26.7% of the medical records analyzed had nursing records classifi ed as
poor and 64.6% as regular, with only 8.7% classifi ed as good; the magnitude of these proportions is
close to that observed for the nursing records in the present study (46.4% poor and 47.0% regular),
suggesting that documentary weaknesses of this nature are not a one-off phenomenon, but a persistent
pattern in the production of nursing records in Brazilian hospital records, even when the studies are
conducted in different institutions, regions and periods. In the same direction, Dodo et al. (2020),
in an audit of 248 medical records from a public hospital in the northern region of Brazil, classifi ed
only 25.9% of the records as complete, with 67.1% incomplete, an even more critical result than that
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observed in the present study and which reinforces the persistence of the problem even in publications
from the 2020s. Similarly, Silva et al. (2019), in an audit conducted at a university hospital in Salvador,
identifi ed weaknesses in the checking of nursing prescriptions, concluding that the quality of the
records only partially met the recommendations of COFEN, a fi nding qualitatively consistent with
what was observed in this study for the set of items on the general checklist and precautions.
The most signifi cant fi nding of this audit refers to the discontinuity of the stages of the
Nursing Process: while the evolution of nursing, a predominantly descriptive stage, was present in
95.4% of the medical records, the stages of diagnosis (9.9%), implementation (4.6%) and nursing
evaluation (4.6%) were recorded in a substantially smaller proportion. This pattern is consistent with
that described by Pimentel et al. (2023), who, when evaluating 258 medical records from a large
hospital in the Midwest region with the Quality of Diagnoses, Interventions and Outcomes instrument,
validated for Brazil, identifi ed low mean scores for both nursing diagnoses as a process and as a
product, and for the dimensions of nursing interventions and outcomes, with a statistically signifi cant
difference between the hospitalization units analyzed (p < 0.001). The convergence between the two
studies, carried out in different institutions and regions, suggests that the discontinuity of documented
clinical reasoning; present in the evolution, but absent in the diagnosis and evaluation, it is not an
institutional particularity, but a structural pattern of nursing documentation in Brazilian hospitals.
This pattern suggests that the nursing care provided was not being fully documented in the light of the
methodological model in force at the time of the audited hospitalizations, which, according to COFEN
Resolution No. 358/2009, then in force, provided for the organization of the Nursing Process in fi ve
interrelated, interdependent and recurrent stages: data collection, diagnosis, planning, implementation
and nursing evaluation (COFEN, 2009). The concentration of records in the stages of evolution and,
to a lesser extent, planning, without the corresponding record of diagnostic reasoning and evaluation
of the results achieved, compromises the formal demonstration of the nurse’s clinical judgment and
reduces the visibility of the contribution of nursing to the outcomes of care, a purpose that the COFEN
regulation itself attributed to the documented operationalization of the Nursing Process (COFEN,
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2009). The update promoted by COFEN Resolution No. 736/2024, which began to structure the Nursing
Process in evaluation, diagnosis, planning, implementation, and evolution, maintains this requirement
for systematic documentation of all stages (COFEN, 2024a), so that the identifi ed weakness remains
relevant for the current care practice and for any new audits of the institution.
The progressive decline in the completeness of nursing outcomes over the fi rst four days of
hospitalization from 74.2% of outcomes with the eight complete systemic domains on the fi rst day to
46.4% on the fourth day, associated with an increase in the proportion of days without any recorded
evolution, from 6.0% to 43.7%, is an original fi nding of this study. Contrary to a simple sample
oscillation, this decrease was statistically signifi cant when tested in a paired manner by the McNemar
test (χ² with continuity correction = 24.72; p < 0.001), which allows us to state, with statistical
rigor, that the probability of a medical record losing completeness between the fi rst and fourth days
was signifi cantly higher than the probability of the reverse movement. This pattern suggests a real
discontinuity of documented care throughout hospitalization, potentially related to the nursing team’s
work overload, the variation in care complexity throughout hospitalization, or gaps in the culture
of systematic recording regardless of the patient’s length of stay. This fi nding is compatible with
the national literature, which associates the fragility of nursing records with the high demand for
care in relation to the number of professionals available (LOPES; ASCARI, 2016), and reinforces the
relevance of personnel dimensioning instruments based on patient classifi cation systems (FUGULIN;
GAIDZINSKI; KURCGANT, 2005), since underdocumentation tends to be more pronounced on
hospitalization days when, presumably, the team’s workload is more intense.
The low frequency of recording risk assessment scales is another fi nding with direct
implications for patient safety and nursing care management. The lack of registration of the Fugulin
Scale in 84.1% of the medical records is particularly relevant because this scale constitutes, in Brazil, the
main Patient Classifi cation System used to support the dimensioning of the nursing staff (FUGULIN;
GAIDZINSKI; KURCGANT, 2005), currently governed by COFEN Resolution No. 743/2024 and
Normative Opinion No. 1/2024/COFEN, which establish minimum parameters for hours of care per
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patient according to the degree of dependence identifi ed (COFEN, 2024b, 2024c). The documentary
underuse of this instrument compromises the institution’s ability to technically demonstrate the
adequacy of the staff to the care needs of hospitalized patients, with potential repercussions on the
technical responsibility of the nurse responsible for the service. Similarly, the lack of recording of the
Braden Scales (PARANHOS; SANTOS, 1999) and Morse (MORSE, 2009) in 27.8% and 30.5% of
the medical records, respectively, compromises the fulfi llment of patient safety goals related to the
prevention of pressure injuries and falls, incorporated into the National Patient Safety Program since
its inception by Ordinance No. 529/2013 of the Ministry of Health (BRASIL, 2013). The documentary
gap identifi ed may mask both the actual underuse of the instruments and their application without the
corresponding formal record.
The record of intra- and intersectoral transfer or referral presented the largest proportional
gap between the checklists analyzed, with 31.8% of the medical records without any record of the
item when it was pertinent to the case. Secure communication during the transition of care is one of
the international patient safety goals incorporated into the National Patient Safety Program (BRASIL,
2013), and the national literature points out that communication and registration failures between
health professionals are among the causes most frequently associated with incidents and adverse care
events (CAPUCHO; CASSIANI, 2013), which gives additional relevance to this fi nding, particularly
in a large hospital institution, with multiple hospitalization units and an intense fl ow of intersectoral
referrals, as evidenced by the sample distribution of this study, in which 14 medical records were
audited in more than one unit as a result of patient transfer during hospitalization.
Among the precautionary and patient safety items, the registration of the identifi cation bracelet
had the highest relative frequency (82.8%), which is consistent with the historical prioritization of this
goal as the fi rst of the six international patient safety goals adopted by the Ministry of Health, aimed
at the correct identifi cation of the patient before the provision of any care (BRASIL, 2013). Even so,
the persistence of 17.2% of medical records without this basic record indicates that the goal of safe
patient identifi cation, despite being widely disseminated institutionally, was not fully consolidated in
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the documentation of the nursing team in the period analyzed.
The limitations of the present study include: the documental and retrospective design, which
depends on the quality of the data collection of the audit originally carried out and does not allow us to
infer whether the absence of records corresponds to the effective absence of care or only to the failure
of documentation; the impossibility of evaluating interobserver agreement among the three nurses of
the Nursing Division (COPENF) responsible for data collection, which may introduce variability in
judgment between the records qualitatively classifi ed as good, regular or poor; the identifi cation of a
typing inconsistency in the original database (date of discharge prior to the date of admission in one of
the 151 records), treated by means of punctual exclusion from the respective analysis, which reinforces
the need for consistency validation routines at the time of data collection the use of McNemar’s test
restricted to the comparison between the fi rst and fourth days of hospitalization, without modeling the
complete trajectory of completeness over the four days or adjusting for confounding variables such as
hospitalization sector, length of stay, or clinical complexity; and the impossibility of establishing causal
relationships between the quality of the records and the clinical outcomes of the patients, given the
predominantly descriptive design of the study. The scientifi c nursing community is invited to use the
data, the audit instrument and the statistical approach used here as a starting point for future studies,
with an analytical design, with evaluation of interobserver agreement and multivariate modeling of
the completeness of the records over time, in order to deepen the understanding of the determinants
of the quality of nursing records, in the institution studied and in other Brazilian hospital settings, as
well as to evaluate the impact of educational interventions on the indicators described here.
FINAL CONSIDERATIONS
A retrospective audit of 151 medical records of patients admitted to a university hospital
in the Northeast of Brazil showed relevant weaknesses in the quality and completeness of nursing
records, corroborating, with statistically robust data, a pattern already described in other Brazilian
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institutions. Nursing notes and vital signs records were classifi ed as regular or poor in more than nine
out of ten medical records evaluated. The stages of the Nursing Process that were most dependent on
the nurse’s clinical reasoning: diagnosis, implementation and evaluation of nursing, were recorded in
a substantially lower proportion than the evolution stage, evidencing structural discontinuity, and not
incidental, in the documentation of the care method. The completeness of daily evolution decreased
statistically signifi cantly over the fi rst four days of hospitalization (McNemar’s test, p < 0.001), and the
risk assessment instruments, especially the Fugulin Scale, the basis for nursing staff dimensioning,
showed a high proportion of absence of records.
The main original contribution of this study is to demonstrate, with statistical and not just
descriptive rigor, that the quality of nursing documentation is not uniform throughout hospitalization:
it is concentrated in the fi rst days and deteriorates measurably and signifi cantly thereafter, a temporal
pattern rarely quantifi ed with paired tests in the national nursing audit literature. This fi nding shifts
the focus of the discussion from ‘if’ the records are incomplete to ‘when’, along the line of care,
incompleteness sets in; directly actionable information for nursing management, which can direct
document reinforcement strategies to the most vulnerable hospitalization days, instead of generic and
undifferentiated interventions in time.
These fi ndings reinforce the relevance of nursing auditing as a tool for managing the quality
of care and support the prioritization, by the institution studied, of permanent education strategies
aimed at the systematic recording of all stages of the Nursing Process and the completion of risk
assessment scales, as well as the implementation of continuous, and not just punctual, monitoring of
documentary quality indicators, in order to strengthen the traceability of care, technically support
the dimensioning of the nursing staff and contribute to the fulfi llment of the goals of the National
Patient Safety Program. It is also recommended that periodic audits be carried out, with evaluation of
interobserver agreement and stratifi ed analysis by day of hospitalization and by care unit, to verify the
effectiveness of any interventions implemented based on the fi ndings described here.
Finally, it is reaffi rmed that nursing records are the link that makes the Nursing Process
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auditable, communicable and scientifi cally investigable: without systematic documentation, the
care provided remains invisible to management, research and the professional category itself.
It is expected that the data, the audit instrument and the statistical approach presented here will
serve as a methodological basis for researchers interested in the quality of nursing records, in the
Systematization of Nursing Care and in patient safety, encouraging the realization of comparative
studies between institutions, educational interventions tested experimentally and investigations that
deepen the relationship between documentary completeness and clinical outcomes, a research agenda
that is still little explored in the national nursing literature.
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