Elaboration of a nursing record standard for an Emergency Care Unit.

Authors :: Farias DCS
Lima EFA
Batista KM
Cubas MR
Bitencourt JVOV
Primo CC
Source :: Revista da Escola de Enfermagem da U S P [Rev Esc Enferm USP] 2023 May 29; Vol. 57, pp. e20220253. Date of Electronic Publication: 2023 May 29 (Print Publication: 2023).
Publication Year :: 2023
Abstract: Objective: To develop a registration standard with diagnoses, outcomes and nursing interventions for an Emergency Care Unit.<br />Method: This is applied research of technological development developed in three steps: elaboration of diagnoses/outcomes and interventions statements following the International Classification for Nursing Practice; assessment of diagnosis/outcome relevance; organization of diagnosis/outcome and interventions statements according to health needs described in TIPESC.<br />Results: A total of 185 diagnoses were prepared, of which 124 (67%) were constant in the classification, and 61 had no correspondence. Of the 185 diagnoses, 143 (77%) were rated as relevant by 32 experienced emergency room nurses, and 495 nursing interventions were correlated to diagnoses/outcomes.<br />Conclusion: It was possible to build a record standard for the Emergency Care Unit following standardized terminology, containing diagnostic statements/outcomes and relevant interventions for nursing practice assessed by nurses with practice in emergency.