Com base nos Requisitos do Sistema da Qualidade para aplicação da Norma ISO 9002 referente ao "Controle de Documentos", trata o presente estudo de relato de experiência sobre o treinamento "Importância dos registros como medida de avaliação dos cuidados de enfermagem", realizado com profissionais de enfermagem em uma instituição particular que adotou a Gestão da Qualidade. A autora apresenta um formato simplificado de registro para evolução do cliente que atende o nível de conhecimento técnico científico dos diferenciados profissionais da equipe de enfermagem bem como é adequável a nossa realidade hospitalar. Para atingir tal propósito , a autora baseou-se, principalmente, no referencial bibliográfico do Sistema da Qualidade, em estudos referentes à documentação na área de enfermagem, e na própria experiência. Algumas etapas foram implementadas antes do treinamento efetivo, dentre elas o levantamento de opiniões dos profissionais sobre documentação e análise dos registros de enfermagem descritos nos prontuários. A etapa do treinamento visou principalmente apresentar o método SO-SOAR, um formato simplificado de padronização de registro das informações do cliente. A otimização deste processo de melhoria da qualidade para utilização de sistemas eficientes de controle de informações sobre cuidados de enfermagem, resultou na indicação pela consultoria da Inmetro em aprovação e emissão de documento como Instrução de Trabalho de Enfermagem de um hospital privado do Rio de Janeiro.

Based on general guidelines for the application of ISO 9002 norm and, special, on the quality system require reference to the control of documents, then this study presents a report on the training named program "The importance of records in an evaluation measure mem of nursing cares", that given to nursing staff from private institution adjusted to quality management. The author presents a simplified format for patient evolution registrations and records which attends the technical and scientific knowledge of the different members of the nursing team who being also adequate to our hospital reality. To reach this purpose, the author based on herself goal in the o theorical referential on quality system. In such studi related to the nursing area documentation and on her own work experience. I follow some steps before training program was implemented. Among them, an inquiry on the opinion of the nursing personnel involved on the documentation, and an analysis of the nursing records on the patient's promptuary. The training part aimed primarily at introducing the SO-SOAR method, a simplified format of the padronization for patient evolution registrations. The optimization of the quality improvement process on the utilization of an efficient resulted in the indication by INMETRO consultants of the approval and discharge of document as a work instruction for nursing activities at private institution in Rio de Janeiro.

Based on general guidelines for the application of ISO 9002 norm and, special, on the quality system require reference to the control of documents, then this study presents a report on the training named program "The importance of records in an evaluation measure mem of nursing cares", that given to nursing staff from private institution adjusted to quality management. The author presents a simplified format for patient evolution registrations and records which attends the technical and scientific knowledge of the different members of the nursing team who being also adequate to our hospital reality. To reach this purpose, the author based on herself goal in the o theorical referential on quality system. In such studi related to the nursing area documentation and on her own work experience. I follow some steps before training program was implemented. Among them, an inquiry on the opinion of the nursing personnel involved on the documentation, and an analysis of the nursing records on the patient's promptuary. The training part aimed primarily at introducing the SO-SOAR method, a simplified format of the padronization for patient evolution registrations. The optimization of the quality improvement process on the utilization of an efficient resulted in the indication by INMETRO consultants of the approval and discharge of document as a work instruction for nursing activities at private institution in Rio de Janeiro.