Domingos Camila Santana, Boscarol Gabriela Tavares, Souza Cristiane Chaves de, Tannure Meire Chucre, Chianca Tânia Couto Machado, Salgado Patrícia de Oliveira
Universidade Federal de Viçosa, Departamento de Medicina e Enfermagem. Viçosa-MG, Brasil.
Pontifícia Universidade Católica de Minas Gerais Belo Horizonte-MG, Brasil.
Rev Bras Enferm. 2019 Mar-Apr;72(2):400-407. doi: 10.1590/0034-7167-2018-0579. Epub 2019 Apr 18.
To adapt data collection of the Information System software with the nursing process in Intensive Therapy for use in medical and surgical clinic units.
A descriptive study developed in three stages. The first consisted of team training; in the second, the software was applied in clinical practice with 100 patients; and in the third, we analyzed the modifications to be done.
There was inter-observer agreement of 91%, followed by application of the software in 100 patients. In the "patient registration" module, it was suggested the exclusion of one item, inclusion of six and modification of four of them. In the anamnesis screens, no items were flagged to be deleted; 26 inclusions and 7 changes were proposed. In the physical examination screens, it was suggested the exclusion of 31 items, inclusion of 26 and modification of 27.
Modifying information systems and going through stages methodologically constructed and implemented was important.
使信息系统软件的数据收集与重症治疗中的护理流程相适配，以便在医疗和外科临床科室使用。
开展一项分三个阶段的描述性研究。第一阶段为团队培训；第二阶段，该软件在100例患者的临床实践中应用；第三阶段，分析需进行的修改。
观察者间一致性为91%，随后该软件应用于100例患者。在“患者登记”模块中，建议排除一项，纳入六项并修改其中四项。在问诊屏幕中，未标记要删除的项目；建议纳入26项并进行7处修改。在体格检查屏幕中，建议排除31项，纳入26项并修改27项。
修改信息系统并按方法构建和实施的阶段进行很重要。
