ABSTRACT
Objective:
To structure the Computerized Nursing Process using the International Classification for Nursing Practice (ICNP®) version 2.0 to emergency care units in a computerized structure.
Method:
This is a methodological and technological research that followed the stages: (1) establishment of the development team and resources; (2) adequacy of clinical situations, diagnoses and nursing interventions for the emergency area; (3) association of diagnoses and interventions based on ICNP®; (4) organization and codification of clinical evaluation, diagnoses and nursing interventions; (5) transfer of data to the a computerized platform.
Results:
Readjustment and construction of 1,445 possibilities of clinical evaluations associated with 961 different diagnoses and their corresponding interventions to the most frequent situations in emergency services.
Conclusion:
ICNP® has a strong and solid form for the development of the computerized nursing process able to support nurses in safe decision-making to improve the quality of health care.
Descriptors:
Emergency Medical Services; Electronic Health Records; Nursing Diagnosis; Patient Safety; Terminology