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This is a documental type study that analyzed124 nursing records/notes (51 of registered nurses and 73 of practicalnurses). After accomplishing the ethical demands regarding this study,the data was collected from the patients record of the Adult IntensiveCare Unit* and that later were moved out to the Medical or Surgical Unit.It was analyzed the nursing records made in the first three days of thepatient internment in this two units, being used a form with questionsregarding the structure and the aesthetics of them. The results pointedthat 80,4% of the registered nurses didn't put the date close to the nursingcare records and 72,5% omitted the hours. Regarding to the practical nurses,53,5% didn't mention the date and 90,4% noted down just the period correspondingto the shift, but not the hours. It was also observed that a total of57 deletions made by the two categories, the prevalent way of correctionwere to write over the wrong word(s). The presences of general/evasiveterms and abbreviations that difficult the understanding of the nursingcare records was frequent. The data indicate that the records are notwritten in a systematic way, and that can commit its functionality andusefulness as communication instrument for the quality of the nursingcare

Anotações/registros de enfermagem: instrumento de comunicação para a qualidade do cuidado?