Nursing Clinical Documentation System Structured on NANDA-I, NOC, and NIC Classification Systems.
Information is a key feature that health professionals need to exercise their profession with efficiency and quality. This study aims to present the experience of the usage of an electronic system for clinical documentation in nursing in a university hospital. It is a methodological research of technology production. The system was developed in four phases: Conception, Elaboration, Construction, and Transition, and was named Electronic Documentation System of the University of São Paulo Nursing Process (PROCEnf-USP™). The knowledge base of PROCEnf-USP™ was organized in hierarchy of domains and classes, according to NNN linkages.
School of Nursing, University of Sao Paulo, Brazil.
Heloisa Helena C
HH
Peres
School of Nursing, University of Sao Paulo, Brazil.
Diná
D
de Almeida Lopes M da Cruz
Department of Nursing and Health Sciences, California State University East Bay, USA.
Michelle
M
Tellez
School of Nursing, University of Sao Paulo, Brazil.
Rita
R
de Cassia Gengo e Silva
School of Nursing, University of Sao Paulo, Brazil.
Regina Celia
RC
dos S Diogo
University Hospital, University of São Paulo, Brazil.
Diley Cardoso F
DC
Ortiz
School of Nursing, University of Sao Paulo, Brazil.
Dóris R
DR
Ortiz
D001938:Brazil; D020000:Decision Support Systems, Clinical; D004282:Documentation / Q000379:methods* / Q000592:standards; D006801:Humans; D048108:Nursing Informatics / Q000379:methods; D009736:Nursing Process / Q000145:classification*