THE ROLE OF THE NURSE IN MEDICAL RECORD ANALYSIS: MAIN CHALLENGES ENCOUNTERED

Abstract

This study aims to highlight the importance of the nurse’s role in the analysis of medical records, emphasizing the main challenges encountered in this process. The analysis of medical records is a fundamental practice to ensure the quality, continuity, and safety of healthcare, as it allows monitoring of clinical interventions and evaluation of the effectiveness of nursing care. In this context, nurses play a crucial role in verifying the completeness, accuracy, and coherence of recorded information, ensuring that documentation accurately reflects the care provided to patients. Nevertheless, several barriers are identified, including incomplete or inconsistent records, limited time for detailed reviews, lack of institutional standardization, and insufficient training in health information systems. These factors may compromise the reliability of documentation and, consequently, patient safety. Therefore, continuous professional education, the implementation of standardized documentation protocols, and the strengthening of communication within multidisciplinary teams are essential strategies to improve documentation practices and promote safer, higher-quality nursing care.

DOI: https://doi.org/10.56238/edimpacto2025.087-013