Escola Superior de Enfermagem de Lisboa. Av. Prof. Egas Moniz. 1600-096 Lisboa Portugal.
Instituto Português de Oncologia de Lisboa Francisco Gentil. Lisboa Portugal.
Cien Saude Colet. 2021 Feb;26(2):505-510. doi: 10.1590/1413-81232021262.40802020. Epub 2020 Jun 6.
Nursing information systems, where quality indicators are integrated, focus on the standardization of health records and the consequent visibility of the provided care. Despite the acknowledged importance of the contributions of information systems, their implementation has been characterized by several challenges, so we propose to reflect on them. To identify the evidence available in the literature on these same challenges, a narrative review of the literature was developed, with the analysis of relevant articles and reports on this issue. It is clear in the literature the importance of information systems for obtaining quality indicators that are sensitive to nursing care, with a positive impact on the quality of care, allowing for measurable quality in interventions, as well as facilitating inter and intra-institutional comparability, in real-time or in a retrospective analysis. The challenges encountered and which urgently needs to be resolved in clinical practice are related to the difficulty for professionals to perceive the impact of computer records, the visibility of nursing indicators and the time that is allocated in the context of providing care to carry out these records.
护理信息系统将质量指标进行整合，重点关注健康记录的标准化和所提供护理的可见性。尽管信息系统的贡献得到了公认，但它们的实施也存在一些挑战，因此我们建议对此进行反思。为了确定文献中关于这些相同挑战的现有证据，我们对文献进行了叙述性综述，并对相关文章和报告进行了分析。文献清楚地表明，信息系统对于获取对护理敏感的质量指标非常重要，这对护理质量有积极影响，使干预措施的质量可衡量，并有助于实时或回顾性分析中的机构间和机构内可比性。在临床实践中遇到的、迫切需要解决的挑战与专业人员难以感知计算机记录的影响、护理指标的可见性以及在提供护理时分配用于记录这些指标的时间有关。
