Conjunto de dados mínimos de enfermagem para unidade de internação clínica
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Data
2017-02-14
Autores
Brito, Nilza Martins Ravazoli [UNESP]
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
Introdução: O Conselho Federal de Enfermagem (COFEN), por meio da Resolução 358/2009, preconiza que a assistência de enfermagem deve ser sistematizada com a implementação do Processo de Enfermagem (PE). O PE direciona os julgamentos clínicos ao cuidado de enfermagem. Um dos desafios dos profissionais da enfermagem é o uso de um sistema de classificação na prática do cuidado, aliada a recursos tecnológicos disponibilizados pelos Registros Eletrônicos de Saúde (RES). Os RES estruturados a partir de um Conjunto de Dados Mínimos de Enfermagem (CDME) e sistemas de classificação de enfermagem podem contribuir à construção de Sistemas de Informação em Saúde de melhor qualidade. Objetivos: Construir um CDME para unidade de internação clínica. Métodos: Estudo metodológico desenvolvido em quatro etapas. Na primeira etapa, foi realizada a análise documental dos formulários e telas do sistema de informação, utilizados na unidade de clínica médica para registro de enfermagem, de um hospital público do interior do Estado de São Paulo. Na segunda etapa, foram realizadas oficinas com enfermeiros da unidade de clínica médica para determinar o conjunto de dados mínimos de enfermagem, relacionados aos elementos dos cuidados de enfermagem, elementos do paciente e elementos dos provedores de serviços, pertinentes à assistência de enfermagem, tendo como referenciais a classificação de diagnósticos de enfermagem NANDA Internacional (NANDA-I), a Classificação das Intervenções de Enfermagem (NIC) e a teoria de enfermagem das Necessidades Humanas Básicas (NHB). Na terceira etapa, foi realizado mapeamento cruzado entre as prescrições de enfermagem da instituição e intervenções da NIC, validadas pela opinião de expertos em PE. Na quarta etapa, foi construído instrumento para registro de enfermagem em RES, considerando o CDME obtido. Os dados foram analisados pelos referenciais da NANDA-I, da NIC e da teoria das NHB. Resultados: Entre os dados analisados dos formulários, telas eletrônicas e opinião dos enfermeiros os dados de enfermagem foram predominantemente do domínio fisiológico da NANDA-I (66%) e da categoria psicobiológica das NHB (86,4%). Os diagnósticos de enfermagem identificados foram predominantemente do domínio fisiológico (48,4%), assim como das prescrições de enfermagem (56,9%). No mapeamento cruzado entre a lista de prescrições de enfermagem e intervenções da NIC, foram avaliados 256 itens de prescrição, entre estes, o domínio fisiológico básico (38,9%) e complexo (44%) foram predominantes. No mapeamento cruzado, todos os itens tiveram concordância superior a 80% entre os expertos. Partindo dos resultados, foi construído um instrumento de CDME para RES e um ebook. Conclusão: O CDME foi construído com dados utilizados por enfermeiros na assistência e o seu uso reflete a prática assistencial em unidade de internação clínica, favorece a qualidade na construção de RES para registro de enfermagem e oferece indicadores de qualidade assistenciais e gerenciais.
Introduction: By means of Resolution 358/2009, the Brazilian Nursing Federal Council (COFEN) recommends that the nursing care should be systematized through the implementation of the Nursing Process (NP). The NP guides the clinical judgments needed in nursing care. One of the greatest challenges faced by nursing professionals in this process is the use of a classification system in the practice of care, together with technological resources provided by the Electronic Health Records (EHR). These EHR, when structured from a Nursing Minimum Data Set (NMDS) and from nursing classification systems, can contribute to the quality development of Health Information Systems. Objectives: To develop a NMDS for clinical hospitalization units. Methods: Methodological study performed in four stages. At the first stage a documentary evaluation of the screens and forms of the information system used at the clinical unit to register nursing data in a public hospital of the State of São Paulo was conducted. At the second stage, workshops were held with nurses from the medical unit to determine the NMDS related to the nursing care elements, patient elements and to the service providers elements involved in nursing care. It was used as referential the nursing diagnoses classification NANDA International (NANDA-I), the Nursing Intervention Classification (NIC) and the nursing theory Basic Human Needs (BHN). At the third stage, a cross-mapping was made between the nursing prescriptions from the institution and the nursing interventions from the NIC, validated by experts in NP. Finally, at the fourth stage an instrument to support the nursing EHR was developed, according to the obtained NMDS. The data were analyzed by the referential NANDA-I, NIC and BHN theory. Results: Among the analyzed data of the forms, electronic screens and nurses' opinion the nursing data were predominantly about the physiological domain of NANDA-I (66%) and about the psychobiological category of the BHN (86.4%). The nursing diagnoses identified were predominantly in the physiological domain (48.4%), as well as in nursing prescriptions (56.9%). In the cross-mapping between the list of nursing prescriptions and NIC interventions, 256 prescription items were evaluated, among which the predominant basic physiological domain (38.9%) and complex (44%). In this cross-mapping all items had an agreement rate higher than 80% among experts. Based on these results, a NMDS instrument was developed for HER and an ebook. Conclusion: The NMDS was developed based on data used by nurses during nursing care and its use reflect nursing care in clinical hospitalization unit, brings quality in the construction of EHS for nursing registration and provide management and care quality indicators.
Introduction: By means of Resolution 358/2009, the Brazilian Nursing Federal Council (COFEN) recommends that the nursing care should be systematized through the implementation of the Nursing Process (NP). The NP guides the clinical judgments needed in nursing care. One of the greatest challenges faced by nursing professionals in this process is the use of a classification system in the practice of care, together with technological resources provided by the Electronic Health Records (EHR). These EHR, when structured from a Nursing Minimum Data Set (NMDS) and from nursing classification systems, can contribute to the quality development of Health Information Systems. Objectives: To develop a NMDS for clinical hospitalization units. Methods: Methodological study performed in four stages. At the first stage a documentary evaluation of the screens and forms of the information system used at the clinical unit to register nursing data in a public hospital of the State of São Paulo was conducted. At the second stage, workshops were held with nurses from the medical unit to determine the NMDS related to the nursing care elements, patient elements and to the service providers elements involved in nursing care. It was used as referential the nursing diagnoses classification NANDA International (NANDA-I), the Nursing Intervention Classification (NIC) and the nursing theory Basic Human Needs (BHN). At the third stage, a cross-mapping was made between the nursing prescriptions from the institution and the nursing interventions from the NIC, validated by experts in NP. Finally, at the fourth stage an instrument to support the nursing EHR was developed, according to the obtained NMDS. The data were analyzed by the referential NANDA-I, NIC and BHN theory. Results: Among the analyzed data of the forms, electronic screens and nurses' opinion the nursing data were predominantly about the physiological domain of NANDA-I (66%) and about the psychobiological category of the BHN (86.4%). The nursing diagnoses identified were predominantly in the physiological domain (48.4%), as well as in nursing prescriptions (56.9%). In the cross-mapping between the list of nursing prescriptions and NIC interventions, 256 prescription items were evaluated, among which the predominant basic physiological domain (38.9%) and complex (44%). In this cross-mapping all items had an agreement rate higher than 80% among experts. Based on these results, a NMDS instrument was developed for HER and an ebook. Conclusion: The NMDS was developed based on data used by nurses during nursing care and its use reflect nursing care in clinical hospitalization unit, brings quality in the construction of EHS for nursing registration and provide management and care quality indicators.
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Palavras-chave
Processos de enfermagem, Registros de enfermagem, Registros eletrônicos em saúde, Terminologia, Coleta de dados, Informática em enfermagem, Nursing process, Nursing records, Electronic health records, Terminology, Data collection, Nursing informatics