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Elaboration of a nursing record standard for an Emergency Care Unit
Dilzilene Cunha Sivirino Farias1, Eliane de Fátima Almeida Lima1, Karla de Melo Batista1
1Universidade Federal do Espírito Santo, Vitória, ES. Brazil.
Objective:
To develop a registration standard with diagnoses, outcomes and nursing interventions for an Emergency Care Unit.
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.
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.
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.
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