# name
Accuracy and completeness of records of adverse events through interface terminology

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Objective: To determine what adverse events, including pressure ulcers, infection of the surgical site and aspiration pneumonia, nurses record in clinical histories, in terms of diagnostic accuracy and completeness, through ATIC. Method: Observational, descriptive, cross-sectional, multicenter study of 64 medical-surgical and semi-critical units of two university hospitals in Catalonia, Spain, during 2015. e diagnostic accuracy was assessed by means of the correspondence between the event declared in the Minimum Basic Data Set and the problem documented by the nurse. e record was considered complete when it contained the risk of the event, prescriptions of care and a record of the evolution. Results: e sample evaluated included 459 records. e accuracy results of pressure ulcers are highly correlated between the nursing diagnosis recorded and that declared in the Minimum Basic Data Set. e accuracy in surgical site infection is moderate, and aspiration resulting in pneumonia is very low. e completeness of results is remarkable, except for the risk of bronchoaspiration. Conclusion: e adverse event recorded by nurses with greatest accuracy is pressure ulcers.

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Revista da Escola de Enfermagem da USP, 2018, vol. 52, num. e03306

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cc-by (c) Universidade de São Paulo, 2018

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Articles publicats en revistes (Infermeria Fonamental i Clínica)

# metadata.dc.title[].value
Accuracy and completeness of records of adverse events through interface terminology