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CIN: Computers, Informatics, Nursing:
doi: 10.1097/CIN.0000000000000060
Feature Article

The Experience of an Information System for Nursing Practice: The Importance of Nursing Records in the Management of a Care Plan

NUNES, SOFIAR.T. MSc Bioethics, MS Nursing, RN; REGO, GUILHERMINA PhD; NUNES, RUI PhD

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Abstract

Health information systems are becoming common because they are important tools to support decision making and assist nurses in their daily interventions. The Information System for Nursing Practice promotes consistent nursing records, as it is directed to the nursing practice and process. The aims of this study were to identify and describe the most frequent type of nursing actions in the care plan for a patient after acute myocardial infarction, considering the seven-axis model of the International Classification of Nursing Practice and the rate of health education given to patients during hospitalization. A cross-sectional analysis was performed retrospectively by searching the computerized database of the Information System for Nursing Practice. We verified some gaps in information with regard to unidentified records of diagnoses and interventions. During hospitalization, the most used interventions were in the fields of observing (40%) and managing (23%). Interventions associated with management of signs and symptoms were more frequent and were performed in 84.9% of the patients. In the field of informing, health education in relation to diet was performed in 21.7% of the patients; exercise, in 16%; and tobacco, in 11.3%. The use of nursing records and information systems can improve nursing care coordination and care plan management.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

 

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