Avaliação de qualidade do registro eletrônico do processo de enfermagem

Abstract

Ao meu querido esposo Josenildo, pelo amor incondicional, pelo companheirismo, pela paciência sem limites, pelo apoio irrestrito e fundamental, por toda a ajuda na tabulação dos dados e na elaboração das figuras. Agradeço principalmente pelo cuidado constante com a nossa filha nos momentos em que precisei me ausentar para a elaboração deste trabalho. À minha amada filha Júlia Mariane, que traz alegria e cor para os meus dias e me faz acreditar que nada é impossível para Deus. Sua existência me lembra todos os dias que nunca devemos desistir dos nossos sonhos, pois eles se tornam realidade quando acreditamos e lutamos por eles. Aos meus queridos pais João Batista e Rita pelo exemplo de vida, pelo esforço em me educar e pela torcida por meu sucesso.

Avaliação da acurácia diagnóstica em enfermagem: papel versus sistema de apoio à decisão

“…(12) According to these recommendations, the PROCEnf-USP® has a standardized system of language, and minimum nursing data that are set to essential data, which are documented in nursing care. (2,5) In the study, 245 diagnoses indicated by the students, 166 (86 [PROCEnf-USP ® ] and 80 [paper-based]) had zero accuracy, that is, 68% of diagnoses. Phenomena like this are foresee in the literature, which in one clinical situation can be identified as highly accurate diagnoses and in another as low accuracy, which is accomplished by the complexity and subjectivity of nursing diagnoses.…”

“…(2,5) In a previous study, the PROCEnf-USP® was assessed for its quality standard requirements ISO/IEC 25010 and the results indicated that the characteristic "Functional Adequacy" reached the quality required for the necessities considered in the assessment of nursing professors, clinical and surgical doctors, among other units, and computer experts. It was evident that, from a functional point of view, the PROCEnf-USP ® is a tool that meets the needs of users, and enable the execution of Nursing Process based on scientific knowledge.…”

“…It was evident that, from a functional point of view, the PROCEnf-USP ® is a tool that meets the needs of users, and enable the execution of Nursing Process based on scientific knowledge. (2) In Brazil, the area of electronic documentation of the nursing process is marked by systems that can be presented only as a typing of its corresponding paper-based from a check list of diagnoses without the adoption of standardized language.…”

“…(1) Currently, the diversity of professionals involved in patient care and legal demands of maintenance and preservation of records, the volume of paper that needs to be stored reached dimensions difficult to manage, requiring large archiving capabilities. (2,3) Besides facilitating access to information and reducing the volume of stored paper, the Health Electronics Records (HER) can also contribute to the solution of clinical problems, when integrated into Decision Support Systems (DSS).…”

“…(5) The PROCEnf-USP ® can generate diagnostic suggestions from assessment data, clinical alerts and interpretation of data such as vital signs, oxygen saturation and body mass index, as well as evaluation of patient rating scales and pressure ulcers. (2) This DSS has two environments, a professional, which includes the real documentation of clinical assessment of the patient data and an academic, which is intended to increase critical thinking and improve the diagnosis of nursing students thinking. The academic environment has the same characteristics of the work environment, allowing the creation of fictitious patients to encourage learning through simulation of clinical cases with the same characteristics of the real documents.…”