Coherencia diagnóstico/intervención de enfermería en la hoja de registros clínicos y uso de lenguaje estandarizado.

Introduction: The nursing process has been described as the method by which nursing professional practice is scientifically based, which is why it is essential that all professionals know about it and have the skills to carry it out. All this care must be reflected in the clinical record sheet, which is evidence of the impact of nursing interventions on the patient's health. Objective: To identify if there is coherence between the interventions with the nursing diagnosis, as well as the use of standardized language. Methodology: Documental, exploratory, descriptive, retrospective and cross-sectional study in which nursing diagnoses and interventions documented in 51 clinical record sheets were reviewed. Results: Lack of consistency of interventions with nursing diagnosis in 45% of independent interventions and 51% in dependent. Using of standardized language: 78% in diagnostic labels, related factor 25%, 16% in defining characteristics and 22% in independent interventions. Conclusions: There is little consistency of interventions with nursing diagnosis in nursing records, poorly developed and incomplete diagnoses, reflecting incompetence of nurses for management of the nursing process and therefore lack of critical thinking in the study sample. Because the use of standardized language is almost zero, it is imperative promotion for widespread use, its functionality and importance should be taught. [ABSTRACT FROM AUTHOR]