Nursing Clinical Documentation System Structured on NANDA-I, NOC, and NIC Classification Systems.

Area of Science:

• Nursing Informatics
• Health Information Systems
• Technology in Healthcare

Background:

• Effective information management is crucial for healthcare professionals to ensure efficient and high-quality patient care.
• The integration of technology in clinical settings is essential for modernizing healthcare practices.

Purpose of the Study:

• To present the experience of utilizing an electronic system for clinical documentation in nursing within a university hospital setting.
• To describe the development and implementation of a novel electronic nursing process documentation system.

Main Methods:

• Methodological research focused on technology production.
• Development of the Electronic Documentation System of the University of São Paulo Nursing Process (PROCEnf-USP™) through four distinct phases: Conception, Elaboration, Construction, and Transition.
• Organization of the system's knowledge base using a hierarchical structure of domains and classes, aligned with NNN linkages.

Main Results:

• Successful development and implementation of the PROCEnf-USP™ system in a university hospital.
• The system provides an organized, hierarchical knowledge base for nursing documentation.
• Facilitates efficient and quality clinical documentation for nursing professionals.

Conclusions:

• The Electronic Documentation System of the University of São Paulo Nursing Process (PROCEnf-USP™) is a valuable tool for enhancing clinical documentation in nursing.
• Implementation of such systems supports improved efficiency and quality of care in university hospitals.
• The hierarchical organization of the knowledge base, based on NNN linkages, ensures standardized and comprehensive documentation.