title: Conceptualization of an electronic system for documentation of nursing diagnosis, outcomes, and intervention.
abstract: Electronic nursing documentation constitutes technical, scientific, legal, and ethical documents. The objective of this study was to develop an electronic nursing documentation system. The system was developed in four phases (conceptualization, detailing, prototype building, implementation), and the knowledge base was based on domains and classes according to the NANDA-I, NIC, and NOC unified framework. The result is an electronic system (PROCEnf--USP--Nursing Process Electronic Documentation System of the University of São Paulo) which allows documenting nursing process generating reports of nursing process, besides supporting decisions on nursing diagnosis, expected outcomes, and interventions. Integration of different fields of knowledge, as well as the institutional feature of valuing continuous theoretical and practical improvement of nursing process were factors of success of this technological project.
authors.affiliation: Department of Professional Orientation, USP Nursing School, Hospital Universitário de São Paulo. hhcperes@usp.br
authors.forename: Heloisa Helena Ciqueto
authors.initials: HH
authors.lastname: Peres
authors.forename: Diná
authors.initials: D
authors.lastname: de Almeida Lopes Monteiro da Cruz
authors.forename: Antônio Fernandes Costa
authors.initials: AF
authors.lastname: Lima
authors.forename: Raquel Rapone
authors.initials: RR
authors.lastname: Gaidzinski
authors.forename: Diley Cardoso Franco
authors.initials: DC
authors.lastname: Ortiz
authors.forename: Michelle
authors.initials: M
authors.lastname: Mendes e Trindade
authors.forename: Rosangela
authors.initials: R
authors.lastname: Tsukamoto
authors.forename: Neurilene
authors.initials: N
authors.lastname: Batista de Oliveira
mesh_terms: D001938:Brazil; D002984:Clinical Laboratory Information Systems / Q000458:organization & administration*; D004282:Documentation / Q000379:methods*; D057286:Electronic Health Records; D006751:Hospital Information Systems / Q000458:organization & administration*; D017146:Models, Organizational; D009733:Nursing Diagnosis / Q000379:methods* / Q000458:organization & administration*; D048108:Nursing Informatics / Q000458:organization & administration*