Nursing actions identified in the components of a nursing team’s language at a medical office in a hospital-school

Abstract

A descriptive study carried out with the objectives of identifying the terms used by the components of a nursing team in nursing records registered in the patients’ reports to denominate nursing actions, and comparing them to the terms specified in the CIPE Nursing Classification Actions. The retrospective method for the collection of nursing records registered in the patients’ reports was used as well as the process of crossed identification to analyze data from these records. The study was carried out in a medical office of a hospital-school. The sample was composed of 60 reports, which based the transcription of terms that made the identification of 327 nursing actions possible, of which 170 were terms found in the CIPE Classification and 157 were not.