Análise da estrutura categorial da Norma ISO 18104 na documentação em Enfermagem
OBJECTIVE: To verify whether categorical structure of the ISO 18104 standard is adequate to support electronic documentation of nursing actions and nursing diagnoses and to facilitate the development of nursing diagnoses and nursing actions expressions. METHODS: A cross-sectional design with two use...
| Autores: | , , |
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| Tipo de recurso: | artículo |
| Estado: | Versión publicada |
| Fecha de publicación: | 2013 |
| País: | Brasil |
| Institución: | Universidade Federal de São Paulo (UNIFESP) |
| Repositorio: | Repositório Institucional da UNIFESP |
| Idioma: | portugués |
| OAI Identifier: | oai:repositorio.unifesp.br:11600/7547 |
| Acceso en línea: | http://dx.doi.org/10.1590/S0103-21002013000300016 http://repositorio.unifesp.br/handle/11600/7547 |
| Access Level: | acceso abierto |
| Palabra clave: | Nursing informatics Terminology Information technology Medical records systems, computerized Nursing diagnosis Informática em enfermagem Terminologia Tecnologia da informação Sistemas computadorizados de registros médicos Diagnóstico de enfermagem |
| Sumario: | OBJECTIVE: To verify whether categorical structure of the ISO 18104 standard is adequate to support electronic documentation of nursing actions and nursing diagnoses and to facilitate the development of nursing diagnoses and nursing actions expressions. METHODS: A cross-sectional design with two use cases in electronic records from two teaching hospitals that employ different nursing terminologies. RESULT: Case A included 40 diagnostic expressions and 97 interventions. All records for nursing diagnoses included focus, judgment, or clinical finding. All interventions were recorded using action verbs and targets. Few other qualifiers were used. Case B provided two diagnoses and 371 expressions for nursing actions. Diagnoses included focus and judgment. All interventions, except one, were documented using action verbs and targets. CONCLUSION: ISO 18104 was adequate to support documentation of nursing actions and diagnoses expressions. |
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