Elaboration of a nursing record standard for an Emergency Care Unit^*

Elaboración de una norma de registro de enfermería para la Unidad de Atención de Emergencia

ABSTRACT

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.

DESCRIPTORS
Emergencies; Nursing Diagnosis; Electronic Health Records; Standardized Nursing Terminology; Nursing Theory