Objective:

To analyze the nursing focuses/diagnoses documented by rehabilitation nurses during the process of dying in a hospital context.

Method:

it is a descriptive, retrospective and quantitative study conducted at a hospital in northern Portugal in February 2017. The data on documentation of nursing outbreaks/diagnoses identified in clients who died in 2016 were collected using two information systems: SClinic and BICUcare.

Results:

From the 4,115 records made by 148 specialist nurses in rehabilitation nursing, we found that despite the evolution that has taken place over the last decade in the documentation of nursing care, some concerns stand out about that practice of care. Due to the emphasis placed on documenting changes in the field of function, specialist nurses in rehabilitation nursing tend to underestimate the record of changes and needs that emerge from the transitions experienced by people, specifically during death and dying processes.

Conclusion:

Given that the information recorded contributes to the visibility of the care provided, there is a need to adopt strategies that solve the problem of underdocumentation, particularly in the face of death and dying processes.

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