Implementation of Electronic Records Related to Nursing Diagnoses

INTRODUCTION The quality of nursing care is related to the execution of the nursing process, which should be properly documented. In this context, there is an evident need to implement electronic health records with the use of standardized languages. OBJECTIVE To implement electronic records related to nursing diagnoses in a computerized health management system. METHODOLOGY The project followed four stages, based on the plan-do-check-act tool. This tool guided the activities to be carried out in the axes: planning, execution of activities, evaluation, and action. The activities performed included: registration of nursing diagnoses and related factors, as well as the association of these in the Tasy software, test execution, and applicability assessment. RESULTS We included 229 nursing diagnoses and these were associated with 1,664 related factors, a decision tree with 436 defining characteristics was also constructed, which allows the software to suggest nursing diagnoses according to the related signs and symptoms. CONCLUSION The practical consolidation of the steps of the nursing process was verified as well as the possibility of nurses assessing the patients by way of a clinical reasoning and decision making in coherence with the human needs of the patient.