title: Terms used by nurses in the documentation of patient progress.
abstract: Objective Describe the terms used in written records of patients' progress by nurses. Methods Descriptive research with a quantitative method that used a software to extract terms related to 148,200 nursing documentations of patient's progress, from 2010 to 2012, in a university hospital in Curitiba - Paraná. The terms were normalized, if appropriate, in spelling, gender, number and tense; then corpus of 2.638 terms was classified for analysis. Results There were problems related to the identification of the records; the use of trade names for designating artifacts used in the nursing practice; unconventional acronyms and abbreviations; and colloquial terms. Records of terms contained in standardized language of nursing diagnoses were found. Conclusion The language used by nurses is heterogeneous. There is a tendency to use terms of specialized language, even when there is no formal terminology standardization in the institution.
authors.affiliation: Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brasil.
authors.forename: Denilsen Carvalho
authors.initials: DC
authors.lastname: Gomes
authors.affiliation: Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brasil.
authors.forename: Marcia Regina
authors.initials: MR
authors.lastname: Cubas
authors.affiliation: Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brasil.
authors.forename: Luiz Eduardo
authors.initials: LE
authors.lastname: Pleis
authors.affiliation: Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brasil.
authors.forename: Marcos Augusto Hochuli
authors.initials: MA
authors.lastname: Shmeil
authors.affiliation: Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brasil.
authors.forename: Ana Paula Veiga Domiciano
authors.initials: AP
authors.lastname: Peluci
mesh_terms: D000004:Abbreviations as Topic; D001938:Brazil; D006785:Hospitals, University; D006801:Humans; D009733:Nursing Diagnosis; D009737:Nursing Records; D012984:Software; D000072917:Standardized Nursing Terminology; D009626:Terminology as Topic