Restructuring of the medical records of the elderly and construction of an instrument for recording nursing care: an experience report

This study aims to describe the experience of nursing students on the restructuring of the medical record of the elderly and elaboration of an instrument for recording nursing care in a Long Stay Institution for the Elderly. This is a descriptive study, type of experience report, on the construction of the pilot model of medical records of the elderly and printed to record the evolution of nursing care and caregivers in a particular institution in the city of Belo Horizonte, in April 2015. There was a visit to the institution in which it was detected the need to build a model of medical records of the elderly and printed to record the evolution of nursing care and caregivers provided to the elderly. The construction was divided into 4 stages: interaction with the nurse in charge, knowledge about the medical record and nursing records, the preparation of the pilot model and delivery. It was possible to observe how the insertion of the medical record organized for records of nursing activities and caregivers became fundamental for the maintenance of ethical and human precepts that guide care and giving visibility to the nurse, as regards the implementation of the phases of the care process.