The Experience of an Information System for Nursing Practice

Abstract

Health information systems are becoming common because they are important tools to support decision making and assist nurses in their daily interventions. The Information System for Nursing Practice promotes consistent nursing records, as it is directed to the nursing practice and process. The aims of this study were to identify and describe the most frequent type of nursing actions in the care plan for a patient after acute myocardial infarction, considering the seven-axis model of the International Classification of Nursing Practice and the rate of health education given to patients during hospitalization. A cross-sectional analysis was performed retrospectively by searching the computerized database of the Information System for Nursing Practice. We verified some gaps in information with regard to unidentified records of diagnoses and interventions. During hospitalization, the most used interventions were in the fields of observing (40%) and managing (23%). Interventions associated with management of signs and symptoms were more frequent and were performed in 84.9% of the patients. In the field of informing, health education in relation to diet was performed in 21.7% of the patients; exercise, in 16%; and tobacco, in 11.3%. The use of nursing records and information systems can improve nursing care coordination and care plan management.

Nursing Diagnoses for Coronavirus Disease, COVID‐19: Identification by Taxonomic Triangulation

“…Professional care is based on theoretical models and applies a defined six-step nursing process: assessment, diagnosis, planning, intervention, and evaluation (Echevarría Pérez, 2016;Herdman & Kamitsuru, 2017). This process is represented by standardized languages, which provide elements and interrelations as an intermediate theory that allows to elaborate a description of care as a reality phenomenon (Butcher, Bulechek, Dochterman, & Wagner, 2018;de Oliveira Lopes, da Silva, & Herdman, 2017;Herdman & Kamitsuru, 2017;Moorhead, Swanson, Johnson, & Maas, 2018;Nunes, Rego, & Nunes, 2014).…”

Usability Evaluation by Nurses of a Knowledge-Based System of Care Plans for People Hospitalized by COVID-19

“…4,8,[11][12][13] These taxonomies offer elements and interrelationships as an intermediate theory that describe care as a phenomenon. 14,15 Recorded data on caring for individuals provide valuable information for measuring impact on health outcomes. 16 In addition, these records in clinical history have a legal and research function because they represent the service provided.…”

“…These care plans can be recorded in the clinical records (electronic or paper) using standardized languages such as the North American Nursing Diagnosis Association (NANDA-I), Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC) taxonomies 4,8,11–13 . These taxonomies offer elements and interrelationships as an intermediate theory that describe care as a phenomenon 14,15 …”

Registered Nurses’ and Medical Doctors’ Experiences of Patient Safety in Health Information Exchange During Interorganizational Care Transitions: A Qualitative Review

“…[3][4][5] Health information exchange (HIE), defined as "the electronic movement of health-related information among organizations according to nationally recognized standards," 6 can be used to reduce treatment delays and improve patient safety through safe and efficient data management. [7][8][9][10] However, poor HIE usability and functionality, including interoperability problems, can contribute to adverse events and patient harm. 7,10,11 Inadequate and incomplete documentation, along with disruptions in information transfer, is severe risks to patient safety.…”

“…The care paths and care transitions of today’s health care patients are dysfunctional and discontinuous 1,2 because of deficiencies in information transfer and inadequate written communication between hospitals and other health care organizations 3–5 . Health information exchange (HIE), defined as “the electronic movement of health-related information among organizations according to nationally recognized standards,” 6 can be used to reduce treatment delays and improve patient safety through safe and efficient data management 7–10 . However, poor HIE usability and functionality, including interoperability problems, can contribute to adverse events and patient harm 7,10,11 …”