title: [Integration of the nursing process in the electronic health record in an university hospital].
abstract: OBJECTIVE
  To describe the process of implementation of Individualized Care Plan in the Electronic Health Record and its impact on the University Hospital Alcorcón Foundation.
  
  
  METHODS
  Working groups of staff nurses who analyzed activities usually performed to create a catalog of diagnoses, outcomes and interventions. A group of referents that refined the catalog to make it manageable was created. A training plan, nursing assessment forms and the Nursing Discharge Report were designed.
  
  
  RESULTS
  In February 2016 the new methodology was implemented in inpatient units of adults. Between 74.86 and 88.18% of the patients underwent a care plan with the new methodology. Between 69.41 and 76.25% of patients are discharged with a Nursing Discharge Report accordance with regulations. An increase of 24.1% of patients with Nursing Discharge Report after implantation is observed (P=.000; RR: 1.46; 95% CI 1.36-1.56). A total of 116 nurses has been trained.
  
  
  CONCLUSIONS
  In the study conditions, the use of nursing taxonomies has generated thinking skills and allowed nurses to issue judgments, ensure quality of care, and implementing interventions with a planned results. The nursing taxonomy and care plan in the Electronic Health Record have increased interprofessional communication to improve continuity of care through improved Nursing Discharge Report.
authors.affiliation: Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España. Electronic address: dguadarrama@fhalcorcon.es.
authors.forename: D
authors.initials: D
authors.lastname: Guadarrama-Ortega
authors.affiliation: Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
authors.forename: P
authors.initials: P
authors.lastname: Delgado-Sánchez
authors.affiliation: Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
authors.forename: M
authors.initials: M
authors.lastname: Martínez-Piedrola
authors.affiliation: Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
authors.forename: E M
authors.initials: EM
authors.lastname: López-Poves
authors.affiliation: Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
authors.forename: M
authors.initials: M
authors.lastname: Acevedo-García
authors.affiliation: Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
authors.forename: C
authors.initials: C
authors.lastname: Noguera-Quijada
authors.affiliation: Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
authors.forename: J L
authors.initials: JL
authors.lastname: Camacho-Pastor
mesh_terms: D057286:Electronic Health Records / Q000458:organization & administration; D006785:Hospitals, University; D006801:Humans; D009736:Nursing Process / Q000458:organization & administration
keywords: Atención de enfermería; Electronic health records; Informática aplicada a la enfermería; Nursing care; Nursing informatics; Nursing processes; Patient care planning; Planificación de atención al paciente; Procesos de enfermería; Registros electrónicos de salud