title: [Implementation of the nursing process in a radiotherapy unit: development of a medical record].
abstract: The goal of our service is to systematize the nursing care provided to the clients with gynecological and mammary cancer who underwent radiation therapy, using the nursing process, the North American Nursing Diagnosis Association (NANDA) taxonomy and collaborative problems in the diagnoses phase. Therefore, we created a record card in which we briefly reported the relevant data to nursing care, containing: anamnesis, general explanations about treatment, main collaborative problems, nursing diagnoses, interventions, outcomes and evolution. This card was tested in service and evaluated by the group that had created it regarding content and design, enabling the elaboration of its last version that is presented in the article.
authors.affiliation: Departamento de Enfermagem da Faculdade de Ciências Médicas e Enfermeira do Programa de Educação Continuada da Divisão de Enfermagem do CAISM, Endereço: Rua: Conceição, 552-Ap. 25-Centro-CEP: 13010-050, Universidade Estadual de Campinas, Brasil.
authors.forename: Ana Francisca
authors.initials: AF
authors.lastname: Vaz
authors.forename: Denise Diniz
authors.initials: DD
authors.lastname: Macedo
authors.forename: Edina Tavares de Lima
authors.initials: ET
authors.lastname: Montagnoli
authors.forename: Maria Helena
authors.initials: MH
authors.lastname: Lopes
authors.forename: Regina Célia
authors.initials: RC
authors.lastname: Grion
mesh_terms: D001291:Attitude of Health Personnel; D001943:Breast Neoplasms / Q000451:nursing / Q000532:radiotherapy*; D005260:Female; D005833:Genital Neoplasms, Female / Q000451:nursing / Q000532:radiotherapy*; D006801:Humans; D009733:Nursing Diagnosis; D009736:Nursing Process / Q000458:organization & administration*; D009737:Nursing Records; D009859:Oncology Nursing; D011878:Radiotherapy / Q000009:adverse effects