Registos eletrónicos de saúde realizados pelos enfermeiros no cuidado à pessoa em situação perioperatória.

Background: Electronic health records kept by nurses when caring for perioperative patients are essential for ensuring the quality and safety of care. Objective: To identify the nursing focuses and interventions reported by nurses in electronic health records when caring for perioperative patients. Methodology: A retrospective observational study was conducted in the Central Operating Room and the Ambulatory Surgery Unit. The nursing documentation in the electronic health records kept from December 2016 to December 2022 were analyzed, in a total of 50,732 nursing focuses and 451,003 interventions. Results: The most frequently identified nursing diagnoses in nursing records were hypothermia (35.5%) and surgical wound (34.7%). Nursing interventions with referential integrity were of the observing type. Conclusion: Th nursing records about perioperative patients in the health information system focus on surveillance parameters related to safety and infection during the intraoperative period. [ABSTRACT FROM AUTHOR]