Avaliação de sistema eletrônico para documentação clínica de enfermagem

Abstract

Objective: To present the evaluation of an electronic system for documenting the nursing process (NP) from the perspective of nurse users. Methods: This exploratory, descriptive study was conducted with 16 nurses at the University Hospital at the University of São Paulo. The nurses assessed modules and system screens of the Electronic Documentation System of the Nursing Process of the University of São Paulo (PROCEnf -USP) judging visual comfort, handling, clarity and completeness of documentation, objectivity and adequacy of the information content of the nursing record in clinical and surgical units. Results: The majority of the nurses evaluated the functional characteristics of the PROCEnf-USP as excellent or very good, highlighting the clinical reasoning support for decisions about diagnoses, outcomes and nursing interventions. All positioned themselves favorably to the implementation of PROCEnf-USP. Conclusion: The results of the evaluations showed that the nurses are encouraged to acquire new technical skills and technology, with the adoption of PROCEnf-USP, for the documentation of the NP in the institutional reality.