用于记录护理诊断、结果和干预措施的电子系统的概念化设计。

Conceptualization of an electronic system for documentation of nursing diagnosis, outcomes, and intervention.

作者信息

Peres Heloisa Helena Ciqueto, de Almeida Lopes Monteiro da Cruz Diná, Lima Antônio Fernandes Costa, Gaidzinski Raquel Rapone, Ortiz Diley Cardoso Franco, Mendes e Trindade Michelle, Tsukamoto Rosangela, Batista de Oliveira Neurilene

机构信息

Department of Professional Orientation, USP Nursing School, Hospital Universitário de São Paulo.

出版信息

Stud Health Technol Inform. 2010;160(Pt 1):279-83.

PMID:20841693

Abstract

Electronic nursing documentation constitutes technical, scientific, legal, and ethical documents. The objective of this study was to develop an electronic nursing documentation system. The system was developed in four phases (conceptualization, detailing, prototype building, implementation), and the knowledge base was based on domains and classes according to the NANDA-I, NIC, and NOC unified framework. The result is an electronic system (PROCEnf--USP--Nursing Process Electronic Documentation System of the University of São Paulo) which allows documenting nursing process generating reports of nursing process, besides supporting decisions on nursing diagnosis, expected outcomes, and interventions. Integration of different fields of knowledge, as well as the institutional feature of valuing continuous theoretical and practical improvement of nursing process were factors of success of this technological project.

摘要

电子护理文档构成了技术、科学、法律和伦理文件。本研究的目的是开发一个电子护理文档系统。该系统分四个阶段开发（概念化、细化、原型构建、实施），知识库基于NANDA - I、NIC和NOC统一框架的领域和类别。结果是一个电子系统（PROCEnf--USP--圣保罗大学护理过程电子文档系统），它除了支持护理诊断、预期结果和干预措施的决策外，还允许记录护理过程并生成护理过程报告。不同知识领域的整合，以及重视护理过程持续理论和实践改进的机构特点是这个技术项目成功的因素。