Construção de um software-protótipo para registro eletrônico das Anotações de Enfermagem
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Data
2020-02-28
Autores
Arantes, Juliana
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Universidade Estadual Paulista (Unesp)
Resumo
As deficiências relacionadas às Anotações de Enfermagem mostram a fragilidade da assistência prestada. Os erros cometidos nos registros de Enfermagem na assistência ao paciente causam impactos negativos para as instituições de saúde, tanto no cuidado direto ao paciente, como no setor financeiro. Essas ações levam as glosas hospitalares, que é o não pagamento das prestações de serviços realizados. O objetivo deste trabalho foi desenvolver um software-protótipo para o registro eletrônico das Anotações de Enfermagem. A metodologia utilizada aplicou a realização de uma revisão integrativa de literatura com o objeto de estudo, as Anotações de Enfermagem, e para desenvolvimento do protótipo se utilizou a engenharia de software, contemplando as fases de definição, desenvolvimento e avaliação. A construção do software ocorreu por meio do Microsoft Visual Studio®, que possui um ambiente de desenvolvimento integrado, com programação orientada a objetos, utilizando principalmente a linguagem de programação C# (C SHARP). O software construído foi norteado por deficiências identificadas acerca das inconformidades dos registros. Os resultados apresentados envolveram o desenvolvimento do programa, os layouts das telas do software contemplando as principais necessidades encontradas na literatura sobre déficits das Anotações de Enfermagem. O software-protótipo englobou a necessidade de ser um programa de fácil manipulação, intuitivo e que atendesse aos requisitos do Conselho de Classe, tendo como base o Guia de recomendações para registro de Enfermagem no prontuário do paciente e outros documentos de Enfermagem do COFEN.
The deficiencies related to the Nursing Notes show the fragility of the assistance provided. The errors made in the nursing records in patient care cause negative impacts for health institutions, both in direct patient care and in the financial sector. These actions lead to hospital disallowances, which is the non-payment of services rendered. The objective of this work was to develop a prototype software for the electronic registration of Nursing Notes. The methodology used applied an integrative literature review with the object of study, the Nursing Notes, and for the development of the prototype, software engineering was used, covering the phases of definition, development and evaluation. The software was built using Microsoft Visual Studio®, which has an integrated development environment, with object-oriented programming, using mainly the C # programming language (C SHARP). The software built was guided by deficiencies identified about the nonconformities of the records. The results presented involved the development of the program, the layouts of the software screens contemplating the main needs found in the literature on deficits in Nursing Notes. The prototype software encompassed the need to be a program that is easy to handle, intuitive and that meets the requirements of the Class Council, based on the Guide for recommendations for registering Nursing in the patient's record and other COFEN Nursing documents.
The deficiencies related to the Nursing Notes show the fragility of the assistance provided. The errors made in the nursing records in patient care cause negative impacts for health institutions, both in direct patient care and in the financial sector. These actions lead to hospital disallowances, which is the non-payment of services rendered. The objective of this work was to develop a prototype software for the electronic registration of Nursing Notes. The methodology used applied an integrative literature review with the object of study, the Nursing Notes, and for the development of the prototype, software engineering was used, covering the phases of definition, development and evaluation. The software was built using Microsoft Visual Studio®, which has an integrated development environment, with object-oriented programming, using mainly the C # programming language (C SHARP). The software built was guided by deficiencies identified about the nonconformities of the records. The results presented involved the development of the program, the layouts of the software screens contemplating the main needs found in the literature on deficits in Nursing Notes. The prototype software encompassed the need to be a program that is easy to handle, intuitive and that meets the requirements of the Class Council, based on the Guide for recommendations for registering Nursing in the patient's record and other COFEN Nursing documents.
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Palavras-chave
Registros de Enfermagem, Informática em Saúde, Auditoria em Enfermagem, Processo de Enfermagem, Software, Health informatics, Nursing audit, Nursing process, Nursing records