Evaluación de reportes de enfermería de las unidades asistenciales de salud de la red pública de Guayaquil

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Aboagla, R., Osman, M., Elshafie, S., Ahmed, L., Othman, M., Elbashier, M., Abbas, K., Ali, N., & Abdalla, E. (2025). Improving Documentation of Intravenous Cannulation in a Resource-Limited Teaching Hospital: A Two-Cycle Quality Improvement Audit. Cureus, 17(11), 96. https://doi.org/10.7759/cureus.96186

Ahmed, M., Malik, S., Ng, A., & Tariq, S. (2023). Audit of Documentation of Chest Drain Insertion Procedures Before and After Introduction of a Chest Drain Pro forma. Clinical Audit, 15(2), 1-5. https://doi.org/10.2147/CA.S398594

Ameyaw, E., Amoah, R., Njue, C., Tran, N., & Dawson, A. (2022). Audit of documentation accompanying referred maternity cases to a referral hospital in northern Ghana: A mixed-methods study. 22(1), 347. https://doi.org/10.1186/s12913-022-07760-6

Andersson, J., Imberg, S., & Rosengren, K. (20022). Documentation of pressure ulcers in medical records at an internal medicine ward in university hospital in western Sweden. Nursing Open, 10(3), 1794-1802. https://doi.org/10.1002/nop2.1439

Awad, M., Mohamednour, M., Rafat, F., Altijani, M., Elfatih, A., Alkheder, M., Elhado, M., & Yahya, A. (2024). Documentation of Inpatient Medical Records: A Clinical Audit. Clinical Audit, 16, 9-17. https://doi.org/10.2147/CA.S451630

Bail, K., Merrick, E., Bridge, C., & Redley, B. (2021). Documenting patient risk and nursing interventions: Record audit. 38(1), 36-44. https://doi.org/10.37464/2020.381.167

Chen, M., Tan, Z., & Padman, R. (2020). Social determinants of health in electronic health records and their impact on analysis and risk prediction: A systematic review. Journal of the American Medical Informatics Association : JAMIA, 27(11), 1764-1773. https://doi.org/10.1093/jamia/ocaa143

Curley, M. A. Q., Zalon, M. L., Seckel, M. A., Alexandrov, A. W., Sorce, L. R., Kalvas, L. B., Hooper, V. D., Balas, M. C., Vollman, K. M., Carr, D. S., Good, V. S., Latham, C. L., Carrington, J. M., Hardin, S. R., & Odom-Forren, J. (2024). Call to action: Blueprint for change in acute and critical care nursing. Nursing Outlook, 72(6), 102271. https://doi.org/10.1016/j.outlook.2024.102271

Ebbers, T., Kool, R., Smeele, L., Dirven, R., Van, G., & Takes, R. (2022). The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study. 46(7), 46. https://doi.org/10.1007/s10916-022-01837-9

Ferreira, R. P. C. M., Narciso, B. F., Ramos, A., Mendes, S., Palma, S., Ferreira, Ó. M. R., & Baixinho, C. L. (2025). The Documentation Used by the Nurses During the Transition From the Hospital to the Community Setting: A Scoping Review. Nursing Open, 12(3), e70148. https://doi.org/10.1002/nop2.70148

Forsner, M., Mörelius, E., & Hanberger, L. (2021). Questionnaires to measure process and structure of quality indicators for pediatric nursing. 6(1), 381. https://doi.org/10.1097/pq9.0000000000000381.

Gefen, A., Alves, P., Ciprandi, G., Coyer, F., Milne, C., Moore, Z., Payan, Y., & Schlüer, A. (2022). Device-related pressure ulcers: SECURE prevention. Second edition. 31(Sup3a), S1-S72. https://doi.org/10.12968/jowc.2022.31.Sup3a.S1

Gkiala, A. (2022). Assessing the Correct Documentation of Time and Physician Information on Medical Records in the Emergency Department of Queen’s Hospital: An Audit and Re-audit. Cureus, 14(12), e33000. https://doi.org/10.7759/cureus.33000

Gómez, D. T. (2021). Indicadores de evaluación de los registros clínicos de enfermería: Implementación de una herramienta tecnológica. Horizonte Sanitario, 20(3), 315-328. https://doi.org/10.19136/hs.a20n3.3938

Hants, L., Bail, K., & Paterson, C. (2023). Clinical decision-making and the nursing process in digital health systems: An integrated systematic review. Journal of Clinical Nursing, 32(19-20), 7010-7035. https://doi.org/10.1111/jocn.16823

Heaney, K., Shams, R., Nwefo, R., Kane, R., Gordon, J., Laffan, A., Stare, S., & Dullabh, P. (2025). Electronic Health Record Data Collection Practices to Advance Standardization and Interoperability of Patient Preferences for Interpretation Services: Qualitative Study. 27(1), e62670. https://doi.org/10.2196/62670

Holt, E. W., Murarka, S. M., Zhao, Z., Baker, M. V., Omosigho, U. R., & Adam, R. A. (2023). Investigating disparities in compliance of nursing pain reassessment for obstetrics and gynecology patients. American Journal of Obstetrics and Gynecology, 229(3), 314.e1-314.e11. https://doi.org/10.1016/j.ajog.2023.06.027

Jayatilake, D., & Oyibo, S. (2025). Interpretation and Misinterpretation of Medical Abbreviations Found in Patient Medical Records: A Cross-Sectional Survey. 15(9), 447. https://doi.org/10.7759/cureus.44735

Jepkosgei, J., Gathara, D., Mbuthia, D., Wanyama, C., Aluvaala, J., English, M., & Nzinga, J. (2025). Co-design and implementation of nursing handover improvement tool in Kenyan newborn units: A pilot study. 24(1), 1329. https://doi.org/10.1186/s12912-025-03955-4

Joshi, N., Bakshi, H., Chatterjee, A., & Bhartia, S. (2022). Initiative to improve quality of paediatric ward-round documentation by application of «SOAP» format. BMJ Open Quality, 11(1), e001472. https://doi.org/10.1136/bmjoq-2021-001472

Kae, M. (2025). Discharge preparation and readiness after birth: A scoping review of global policies, guidelines and literature. 3(2). https://doi.org/10.1186/s12884-022-04577-3

Koh, J., & Ahmed, M. (2021). Improving clinical documentation: Introduction of electronic health records in paediatrics. 10(3), 9-18. https://doi.org/10.1136/bmjoq-2020-000918

López, M., Fernández, M., Martín, B., Muñoz, M., & Jiménez, J. (2022). Auditing completion of nursing records as an outcome indicator for identifying patients at risk of developing pressure ulcers, falling, and social vulnerability: An observational study. 30(4), 1061-1068. https://doi.org/10.1111/jonm.13569

Luna, D., Francisco, L., López, M., Blasco, D., & González, V. (2024). Optimized Continuity of Care Report on Nursing Compliance and Review: A Retrospective Study. 14(3), 2095-2106. https://doi.org/10.3390/nursrep14030156

McCarthy, S., Motala, A., Lawson, E., & Shekelle, P. (2025). Use of structured handoff protocols for within-hospital unit transitions: A systematic review from Making Healthcare Safer IV. 34(10), 680-690. https://doi.org/10.1136/bmjqs-2024-018385

Muhammed, A., Fakher Aldeen Noman, F. A. R., Abdalgadir, M., Ahmed, W., Alkhider, L., Ziada, M., Ali, M., Mohamed, E., Elzain, M., Alrawi, M., & Alzain, M. (2025). A Structured Approach to Discharge Documentation: Lessons from Dongola Specialized Hospital. Cureus, 17(4), e81696. https://doi.org/10.7759/cureus.81696

Nool, I., Tupits, M., Parm, L., Hõrrak, E., & Ojasoo, M. (2023). The quality of nursing documentation and standardized nursing diagnoses in the children’s hospital electronic nursing records. 34(1), 4-12. https://doi.org/10.1111/2047-3095.12363

Oliveira, N., & Peres, H. (2023). Quality of the documentation of the Nursing process in clinical decision support systems. 29(8), 3426. https://doi.org/10.1590/1518-8345.4510.3426

Ovando, R. V., Martínez, J. A. A., Orozco, G. L., Vázquez, R. S., Estela, M. A. I., Lavariega, G. D. la R., Alarcón, C. R. O., & Mora, G. L. (2022). Calidad de los registros clínicos de enfermería en una institución de salud del puerto de Veracruz: Quality of nursing clinical records in a health institution in the port of Veracruz. South Florida Journal of Development, 3(1), 940-950. https://doi.org/10.46932/sfjdv3n1-072

Peivandi, S., Ahmadian, L., Farokhzadian, J., & Jahani, Y. (2022). Evaluation and comparison of errors on nursing notes created by online and offline speech recognition technology and handwritten: An interventional study. BMC Medical Informatics and Decision Making, 22(1), 96. https://doi.org/10.1186/s12911-022-01835-4

Pineda, M., Allery, F., Delmestri, A., Sudlow, C., Akbari, A., Wood, A., Collins, G., Petersen, I., Coates, L., Khunti, K., Prieto, D., & Khalid, S. (2024). Ethnicity data resource in population-wide health records: Completeness, coverage and granularity of diversity. 11, 221. https://doi.org/10.1038/s41597-024-02958-1

Ruiz, M. A. V., Santos, J. R. D. L., García, C. D. L. C., Castillo, M. M., & Hernández, N. G. (2024). Calidad de Registros Clínicos de Enfermería de Cuidados Intensivos Neonatales de un Hospital Especializado. Ciencia Latina Revista Científica Multidisciplinar, 8(1), 10249-10268. https://doi.org/10.37811/cl_rcm.v8i1.10337

Soza Diaz, C. D. F., Bazán Sánchez, A. C. L., & Diaz Manchay, R. J. (2020). Percepción de las enfermeras sobre el uso de sus registros para garantizar la continuidad del cuidado. Ene, 14(1). http://scielo.isciii.es/scielo.php?script=sci_abstract&pid=S1988-348X2020000100012&lng=es&nrm=iso&tlng=es

Sugianto, K., Hariyati, R., Galleryzki, A., Koten, E., Sudjiati, E., & Bardah, D. (2022). Completeness Documentation of Fall Risk Management: A Cross-Sectional Study. Iranian Journal of Nursing and Midwifery Research, 27(6), 517-521. https://doi.org/10.4103/ijnmr.ijnmr_109_21

Temesgen, M. H., Brihanu, A., & Teshome, Z. bekele. (2022). Post-operative pain assessment, management compliance with WHO guidelines and its barriers in hospitals of West Shoa zone, central of Ethiopia, 2021. Annals of Medicine and Surgery, 84, 104901. https://doi.org/10.1016/j.amsu.2022.104901

Tolera, G., Badasa, K., Deressa, H., Fayera, H., Chala, M., Deyasa, M., Teshome, S., Edessa, D., Etefa, A., & Akuma, A. (2025). Increasing the rate of nursing process implementation: A quality improvement project at Wollega University Comprehensive Specialized Hospital, 2025. 14(4), 35. https://doi.org/10.1136/bmjoq-2025-003576

Torres-Santiago, M., Zárate-Grajales, R. A., & Matus-Miranda, R. (2011). Calidad de los registros clínicos de enfermería: Elaboración de un instrumento para su evaluación. Enfermería Universitaria, 8(1). https://doi.org/10.22201/eneo.23958421e.2011.1.269

Tůmová, P., & Bártlová, S. (2023). Transferring patient information using the SBAR communication tool for interpretation. Kontakt, 25(3), 185-190. https://doi.org/10.32725/kont.2023.026

Zahid, M., Ijaz, A., Hidayat, W., Jan, M., Rafi, H., Nawaz, H., & Khan, H. (2023). Assessing Adherence to Royal College of Surgeons Guidelines: A Closed-Loop Audit of Operation Notes in a Tertiary Healthcare Unit. 15(9), 4573. https://doi.org/10.7759/cureus.45743

Zavala, D., Gualaquiza, L., Asitimbay, J., & González, J. (2025). La auditoría clínica como garantía del derecho a la seguridad laboral del personal sanitario en el Ecuador. Ciencia y Educación, 6(9.2), 164-175. https://doi.org/10.5281/zenodo.17189136

Zuberi, S., Mustaq, Y., Ijaz, A., Sundar, S., Mohamedali, Z., Patel, K., Joseph, J., & Gurprashad, R. (2024). Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines. Turkish Journal of Surgery, 40(1), 11-18. https://doi.org/10.47717/turkjsurg.2024.6194