护士对病历手工记录系统的态度

[Nurses attitude toward the manual recording system of medical records].

作者信息

dos Santos Sérgio Ribeiro, de Paula Adenylza Flávia Alves, Lima Josilene Pereira

机构信息

Universidade Federal da Paraíba.

出版信息

Rev Lat Am Enfermagem. 2003 Jan-Feb;11(1):80-7.

PMID:12733247

Abstract

The main goal of this work was to identify factors related to nurses' understanding about the manual recording system, through a descriptive-exploratory approach, developed with two hundred nursing professionals working at different hospital institutions located in the city of João Pessoa/Paraíba, Brazil. Data were collected with special forms using the Likert's behavioral scale. Results identified five factors such as: a) lack of knowledge about information systems; b) dissatisfaction with the manual recording system; c) needs of an informatized recording system to be used in nursing care; d) desire to utilize a classification system with all steps of the nursing process; and e) difficulties with nursing diagnosis related to manual recording. Findings demonstrated the dissatisfaction of nursing professionals about the manual recording system, requiring deep changes in the established recording model.

摘要

这项工作的主要目标是，通过描述性探索性方法，对巴西若昂佩索阿市/帕拉伊巴州不同医院机构工作的200名护理专业人员进行研究，以确定与护士对手动记录系统理解相关的因素。使用利克特行为量表通过特殊表格收集数据。结果确定了五个因素，即：a）对信息系统缺乏了解；b）对手动记录系统不满意；c）护理工作中需要使用信息化记录系统；d）希望使用涵盖护理过程所有步骤的分类系统；e）与手动记录相关的护理诊断困难。研究结果表明护理专业人员对手动记录系统不满意，需要对既定的记录模式进行深刻变革。