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Revista de Enfermagem Referência

versión impresa ISSN 0874-0283

Resumen

MOTA, Liliana Andreia Neves da; PEREIRA, Filipe Miguel Soares  y  SOUSA, Paulino Artur Ferreira de. Nursing Information Systems: exploration of information shared with physicians. Rev. Enf. Ref. [online]. 2014, vol.serIV, n.1, pp.85-91. ISSN 0874-0283.  http://dx.doi.org/10.12707/RIII12152.

Theoretical framework: Over the years there has been substantial change in the amount of nursing documentation arising from the daily use of information technologies by health professionals’. Physicians are the greatest consumers of the information collected, processed and documented by nurses, given the relevance of this information to the clinical decision-making process. Objective: To identify and describe the information collected, processed and documented by nurses which is considered to be the most relevant for the medical profession. Methodology: A qualitative exploratory study using participant observation (98 hours) and semi-structured interviews (3) with key-informants, conducted in a hospital setting. Inductive content analysis of field notes and interviews was performed. Results: For physicians, the most relevant information depends on the context of the subject, the action and the professions, and was gathered into three categories: “monitoring parameters”; “medication and therapeutic attitudes”; and “intercurrent data”. Conclusion: Data collection strategies produced valid data to identify the most relevant information categories for physicians (“monitoring parameters”, “medication and therapeutic attitudes” and “intercurrent data”). Relevant information for physicians is not influenced by the person who makes a decision on data collection.

Palabras clave : information systems; documentation; nursing.

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