“influencia de la aplicación del formato soapie de los registros de enfermería y su relación con los aspectos ético legales”

Abstract

Nursing records have great relevance in the clinical record, it is a legal document which reflects the quality of health care, facilitating communication with health personnel and continuity of care, which contributes to the development of the profession and the repercussions at a professional and ethical legal level. The objective of the research was to: Determine the influence of the application of the SOAPIE format of the nursing registers and its relationship with the ethical and legal aspects in the Ambato General Teaching Hospital. It is descriptive and field type. The study population consisted of 140 professionals working in the hospitalization areas. The sample was of 103 professionals, a questionnaire was applied by Vargas and Col, which consists of 18 items using the Likert scale (always, sometimes, never). The results indicate that the clinical records are explicit with the most relevant information of the patient; sometimes they make use of the corrector and abbreviations. In addition, they consider that the SOAPIE would allow to register the information according to a logical order with ethical character and to contribute as support to ethical legal situations. Conclusion: The population surveyed does not use the SOAPIE format for the nursing report, although the records do so in relation to the ethical principles of beneficence, non-maleficence, justice and autonomy. Finally, they considered that the nursing records serve as a fundamental basis to contribute to the identity of the profession, professional autonomy, meet ethical requirements of the user and the profession, legal protection to the user and professional, performance evaluation, research and audit