Introduction:

The clinical record is a document of high value for professionals. Its correct management contributes to improving the quality of care, protecting the legal interests of the patient, workers and entities; in addition it provides information for research and teaching purposes.

Objective:

To design a nursing monitoring record model of the critical patients in the Intensive Care Unit of the Clinical Surgical University Hospital Comandante Faustino Pérez of Matanzas.

Materials and methods:

An analytical, observational, descriptive and cross-sectional study was carried out between January 2022 and July 2023. The universe was made up of 50 nurses and the sample was made up of those who were physically working in the service during the study period, for a total of 31.

Results:

It was possible to diagnose, with the study, deficiencies in the recording of insensible and extraordinary losses of endogenous water.

Conclusions:

It was possible to design a nursing monitoring record model in the care of critical patients, which brings together scientific information on the comprehensive and adequate monitoring of critical patients from the physiological and therapeutic point of view. It was organized in a multidimensional structure, appropriate to the Cuban context that supports the care process.

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