Objective:

Implement a technological tool that facilitates the evaluation of clinical nursing records with indicators applied to each phase of the care process, compared with standards established in six areas of care in a public hospital in the state of Tabasco.

Materials and Methods:

The quantitative research, non-experimental design, descriptive and cross-sectional type, the population of 145,022 nursing clinical records and the sample of 384 patients from six hospitalization and emergency areas of the Hospital Regional de Alta Especialidad “Dr. Gustavo A. Rovirosa Pérez ”, the data collection was carried out from January-December 2018, by means of an instrument composed of six indicators to analyze the quality applied to each of the phases of the nursing process, identification, assessment, NANDA diagnostics, NIC interventions, evaluation of NOC results, and the integrity of the information, the data were processed by means of a previously designed technological tool.

Results:

The total sample of nursing clinical records presented a compliance of 81.2% that corresponds to a standard of regular quality and specifically the services of pediatrics 86.5%, internal medicine 85.9%, gynecology and obstetrics 82.8%, traumatology 80.6% and general surgery 80.3% corresponding to regular quality. In the emergency service, the records are deficient 70.9%. The indicators with the lowest quality were the registration of the diagnostic label 67% and the nursing interventions 66%. The main flaw was the omission of data at the time of documenting.

Conclusions:

The clinical records presented regular quality, it is evident that the annotations of the professional work supported by the nursing process, patient safety, and the importance of quality evaluation with a technological instrument for the continuous improvement.

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