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Publication
Registos de Enfermagem sobre feridas: do texto livre aos conteúdos parametrizados
| Name: | Description: | Size: | Format: | |
|---|---|---|---|---|
| PG_33967 | 2.66 MB | Adobe PDF |
Authors
Advisor(s)
Abstract(s)
O presente projeto de investigação insere-se no âmbito do plano curricular do 4º ano da Licenciatura de Enfermagem da Universidade Fernando Pessoa, e o tema abordado é “O impacto do registo digital com campos pré-definidos na qualidade dos registos de enfermagem no tratamento de feridas”.
O objetivo deste trabalho é avaliar a alteração da documentação dos dados relativos ao tratamento de feridas após a implementação de um sistema de informação estruturado com campos parametrizados e comparar o rigor dos registos entre este e a forma de registar em texto livre, no tratamento de feridas cirúrgicas.
A adoção de sistemas eletrónicos para registos de enfermagem no tratamento de feridas apesar de evidenciar algumas lacunas, permite obter registos mais completos do que com o uso do texto livre pelo que preconiza-se não só a sua implementação mas também a análise com vista ao desenvolvimento e aperfeiçoamento deste tipo de Sistemas de Informação.
This research project is part of the curricular plan of the 4th year of the Degree of in Nursing of the Fernando Pessoa University, and the theme addressed is "The impact of digital registration with an electronic health record system with predefined templates in the quality of nursing records in the treatment of wounds.” The objective of this work is to evaluate the alteration of the documentation of the data related to the treatment of wounds after the implementation of a structured information system with parameterized fields and to compare the accuracy of the registries between this one and the way of registering in free text, in the treatment of wounds surgical procedures. The adoption of electronic systems for nursing records in the treatment of wounds, despite showing some gaps, allows to obtain more complete records than with the use of free text, for which it is recommended not only its implementation but also the analysis for the development and improvement of this type of Information Systems.
This research project is part of the curricular plan of the 4th year of the Degree of in Nursing of the Fernando Pessoa University, and the theme addressed is "The impact of digital registration with an electronic health record system with predefined templates in the quality of nursing records in the treatment of wounds.” The objective of this work is to evaluate the alteration of the documentation of the data related to the treatment of wounds after the implementation of a structured information system with parameterized fields and to compare the accuracy of the registries between this one and the way of registering in free text, in the treatment of wounds surgical procedures. The adoption of electronic systems for nursing records in the treatment of wounds, despite showing some gaps, allows to obtain more complete records than with the use of free text, for which it is recommended not only its implementation but also the analysis for the development and improvement of this type of Information Systems.
Description
Projeto de Graduação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Licenciado em Enfermagem
Keywords
Registos de enfermagem Ferida cirúrgica Registos eletrónicos Texto livre Nurses documentation Surgical wound Electronic health record Free text