Main Article Content
Nursing records are the most reliable source of the quality provided by healthcare personnel; in them, all care provided is presented in an authentic, concise, and brief manner. They serve to monitor the continuity of patient care, as a bridge of information between health professionals, and as legal and legal support. The systems most used by nursing staff to carry out their records are the Nursing Care Process and the recording of subjective and objective data, Interpretations and analysis of the data, Care Plan, Intervention or execution, and Evaluation of the expected results. For the study of this article, the non-experimental direct observation technique was used on a sample of 150 medical records from the emergency area of the San Vicente de Paúl Hospital in Ibarra. The most notable results of this research are the deficiency in the application of the Nursing Care Process, the null existence of training in registries; the recording of information at the end of the shift (85%), poor use of abbreviations (64%), nursing notes with little scientific foundation (89%), intelligible records (55%), with marks and corrector, which highlights improved management of nursing records in the emergency service.