When reviewing a form called SAE, look for more than completed fields. Does the record make it possible to understand what was observed, what care was planned, what happened, and how the person responded? Reading it this way helps identify gaps that a sequence of checked boxes may hide.
This guide covers record review in Brazilian practice. The organizational suggestions are educational examples and should be adapted to your institution’s clinical record and guidance.
What is the current reference?
Cofen Resolution No. 736/2024 addresses the Nursing Process and repealed Resolution No. 358/2009. The term SAE continues to appear in materials and forms, but the instrument’s name alone does not demonstrate that the process has been carried out.
The current stages are Nursing Assessment, Diagnosis, Planning, Implementation, and Evaluation. They are related and revisited as the situation changes. Nursing diagnosis and nursing prescriptions are the nurse’s exclusive responsibilities. Nursing technicians and assistants participate through nursing notes, carrying out prescribed care, and documenting its completion, under the nurse’s guidance and supervision.
The documentation must formally form part of the clinical record, whether paper or electronic. The nurse is responsible for documenting all stages; other team members document information corresponding to their responsibilities. Consult the resolution’s text for the full requirements.
Start with the question the record needs to answer
Imagine receiving a patient whose record says only “care continued.” That phrase does not tell you what care occurred, when, or how the person responded. Adding adjectives does not solve the problem. You need to recover the facts that support the entry.
A useful review starts with specific questions: What was observed? Did the information come from the person’s account, a professional assessment, or another record? When did it happen? What action was performed? What still needs clarification?
Separate observation from interpretation
“Patient worried” may summarize an impression, but it does not show its basis. If the person reports being afraid to walk, describe that report and the relevant observations. Avoid turning a hypothesis into a fact or copying an earlier interpretation without checking that it still applies.
Look for an understandable sequence
Read the records in the order events occurred. Check whether the described action addresses the identified need and whether later information describes the response. A list of isolated interventions may leave the reader unable to understand what changed during the shift.
Review example using a fictional situation
Consider a training exercise: a person says they did not understand how to request help before getting up. The purpose of the exercise is to improve the record’s clarity, without establishing a prescription for a real patient.
- Account: What did the person explain about their question?
- Action performed: What guidance was actually provided, and in what context?
- Response: Was the person able to explain, in their own words, how to ask for help?
- Continuity: Were any questions or follow-up needs left unresolved?
These questions do not replace clinical judgment or the stages of the process. They help show why “education provided” may be insufficient to describe the situation. Do not document a demonstration of understanding if it was not observed.
How to review the electronic clinical record
On a tablet authorized by the institution, read the full content before signing. Automatically completed fields may contain old information. Confirm dates, times, authorship, and the distinction between planned care and care that was performed.
If you use a digital pen, check that the writing or transcription is legible before saving. An incorrectly recognized word can change the meaning. Correct it through the system’s procedure, preserving the traceability your institution requires.
A personal draft serves only the purpose permitted by the facility. It does not replace the official record. Do not transfer patient information to devices, accounts, or applications without institutional authorization.
A final check before finishing
- Do the facts described match what I observed or performed?
- Are the time of the event and the time of the entry clear?
- Did I avoid vague expressions, personal judgments, and unchecked copying?
- Does the text distinguish what has already happened from what remains pending?
- Did I document within my professional responsibilities?
When a gap depends on information you do not have, clarify it with the team through the appropriate channel. Do not fill it by assumption. A useful record makes the sequence of care understandable to those who need to consult it.
See examples of nursing notes.
Discover NurseBrain® Synapse to stay organized throughout your shift.