Objective: To verify whether categorical structure of the ISO 18104 standard is adequate to support electronic documentation of nursing actions and nursing diagnoses and to facilitate the development of nursing diagnoses and nursing actions expressions. Methods: A cross-sectional design with two use cases in electronic records from two teaching hospitals that employ different nursing terminologies. Result: Case A included 40 diagnostic expressions and 97 interventions. All records for nursing diagnoses included focus, judgment, or clinical finding. All interventions were recorded using action verbs and targets. Few other qualifiers were used. Case B provided two diagnoses and 371 expressions for nursing actions. Diagnoses included focus and judgment. All interventions, except one, were documented using action verbs and targets. Conclusion: ISO 18104 was adequate to support documentation of nursing actions and diagnoses expressions.
CITATION STYLE
De Fatima Marin, H., Peres, H. H. C., & Dal Sasso, G. T. M. (2013). Categorical structure analysis of ISO 18104 standard in nursing documentation. ACTA Paulista de Enfermagem, 26(3), 299–306. https://doi.org/10.1590/s0103-21002013000300016
Mendeley helps you to discover research relevant for your work.