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Theoretical framework: Over the years there has been substantial change in the amount of nursing documentation arising from the daily use of information technologies by health professionals. Physicians are the greatest consumers of the information collected, processed and documented by nurses, given the relevance of this information to the clinical decision-making process. Objective: To identify and describe the information collected, processed and documented by nurses which is considered to be the most relevant for the medical profession. Methodology: A qualitative exploratory study using participant observation (98 hours) and semi-structured interviews (3) with key-informants, conducted in a hospital setting. Inductive content analysis of field notes and interviews was performed. Results: For physicians, the most relevant information depends on the context of the subject, the action and the professions, and was gathered into three categories: “monitoring parameters”; “medication and therapeutic attitudes”; and “intercurrent data”. Conclusion: Data collection strategies produced valid data to identify the most relevant information categories for physicians (“monitoring parameters”, “medication and therapeutic attitudes” and “intercurrent data”). Relevant information for physicians is not influenced by the person who makes a decision on data collection. [ABSTRACT FROM AUTHOR]

Theoretical framework: Over the years there have been substantial changes in the amount of documentation in nursing as a result of information technologies that are part of the daily work of health professionals. Physicians are the greatest consumers of the information collected, processed and documented by nurses, given the relevance of this information in the process of clinical decision-making. Objectives: To identify and describe the information collected, processed and documented by nurses that appears most relevant to the medical profession. Methodology: Qualitative and exploratory study using participant observation (98 hours) and interviews (3) with key informants, conducted in the hospital. Inductive content analysis of field notes and interviews. Results: The most relevant information for doctors depends on the context of the subject, action and professions and can be aggregated into three categories: «monitoring parameters»; «medications and therapeutic attitudes»; and «recurrent data». Conclusion: Strategies for data collection are capable of generating valid data for the identification of categories of information most relevant to physicians («monitoring parameters», «medications and therapeutic attitudes» and «recurrent data»). The information relevant for physicians is not influenced by the person who decides that the data are collected. [ABSTRACT FROM AUTHOR]