Rev Bras Enferm. 2026 Aug 21;79:e20250501. doi: 10.1590/0034-7167-2025-0501. eCollection 2026.
ABSTRACT
OBJECTIVES: to analyze the application of the Nursing Process stages in women’s care in Primary Health Care.
METHODS: a cross-sectional study was conducted from May to July 2022 in 17 Basic Health Units across four Brazilian municipalities, involving 25 nurses and 92 medical records. A questionnaire was administered to nurses, and data analysis was performed using descriptive statistics with SPSS® software version 25.0. Medical records were read and analyzed.
RESULTS: the execution of the Nursing Process was partial, and all phases had incomplete records. Assessment and planning were the most prevalent, while nursing diagnosis, implementation, and assessment were the weakest.
CONCLUSIONS: incomplete Nursing Process records compromise the documentation of nursing work regarding patient care, potentially leading to ethical and legal implications for professionals. It is necessary to invest in training and foster professional interest in the Nursing Process application and recording.
PMID:42659507 | DOI:10.1590/0034-7167-2025-0501
