Quality indicators of the nursing process documentation in clinical practice.

Objectives: to propose quality indicators for clinical nursing documentation.

Methods: methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients.

Documentation of the nursing process in public health institutions.

Objective: To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health.

Method: A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations.

Results: Of the 416 sectors studied, 89.