Analysis of the nurse’s notes at an intensive therapy unit


  • Maria Cristina Ferreira Fontes
  • Isabel Amélia Costa Mendes
  • Miyeko Hayashida
  • Maria Celia Barcellos Dalri


Nursing records, Patient admission, Intensive Care Units.


This is a retrospective study of the nurse’s notes taken when patients are admitted to the Intensive Therapy Unit of a teaching hospital in the state of Paraná. As secondary database, we used the files of patients hospitalized in the second semester of 2002. Among the 241 collected files, 187 (77.6%) contained the printed version of the nurse’s notes. Most notes were identified by the nurse’s rubrics (50.3%) or name (38.0%). From the qualitative analysis of the 187 nurse’s notes, we extracted 515 contents, recorded with objective writing (56.6%), readable and clear handwriting (56.6%), correct abbreviations (67.0%), free from errors (95.2%) and shortenings (50.7%). Although most analyzed contents were classified as adequate, we observed flaws in some of the examined characteristics. Such features suggest the need for reflection and further investigation.




How to Cite

Fontes, M. C. F., Mendes, I. A. C., Hayashida, M., & Dalri, M. C. B. (2006). Analysis of the nurse’s notes at an intensive therapy unit. Rev Rene, 7(3). Retrieved from



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