Comparison of nursing interventions performed and the records in a computerized system for primary health care

Abstract

Objective: Compare the interventions performed by the nursing staff in a Primary Health Care Unit with the interventions recorded in the information system Methods: Descriptive, exploratory study conducted in two stages at a Health Unit considered as having good practices in nursing. Stage 1: direct, non-participatory and structured observation for fve days. Stage 2 application of the cross-mapping technique in the activities recorded in the computerized system, adapting them in standardized language for nursing interventions. Results: It was found that 23.5% and 27.2% of the interventions made by the nursing staff and nurses were recorded in the computerized system Conclusion: The computerized system displays insuffcient felds to report the work carried out by the nursing team at the Primary Health Care Unit.