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This descriptive study was carried out in a teaching hospital at São Paulo city and had as objective to identify the phases performance and registration of nursing care systematization and the most frequent nursing diagnoses. Data were collected retrospectively from 135 patients records of three units: Cardiology, Adult Infectious Diseases and Neurosurgery, from January to July, 2002. The phases: history, nursing diagnoses, prescription, evolution and assessment were performed and registered in the three units, however, it was verified systematization gaps performance related to nursing diagnoses registered without the realization of nursing history and nursing prescriptions without evolution. The most frequent nursing diagnosis in the three units was risk for infection.

doaj (doaj: directory of open access journals)

Avaliação da realização e do registro da Sistematização da Assistência de enfermagem (SAE) em um hospital universitário Evalución de la realización y registro de las etapas de la sistematizacion de la atención de enfermeria en un hospital universitário Evaluation of nursing care systematization through the phases of nursing process performance and registration in a teaching hospital