Quality of the documentation of the Nursing process in clinical decision support systems*

Objective: to compare the quality of the Nursing process documentation in two versions of a clinical decision support system. Method: a quantitative and quasi-experimental study of the before-and-after type. The instrument used to measure the quality of the records was the Brazilian version of the Quality of Diagnoses, Interventions and Outcomes, which has four domains and a maximum score of 58 points. A total of 81 records were evaluated in version I (pre-intervention), as well as 58 records in version II (post-intervention), and the scores obtained in the two applications were compared. The interventions consisted of planning, pilot implementation of version II of the system, training and monitoring of users. The data were analyzed in the R software, using descriptive and inferential statistics. Results: the mean obtained at the pre-intervention moment was 38.24 and, after the intervention, 46.35 points. There was evidence of statistical difference between the means of the pre- and post-intervention groups, since the p-value was below 0.001 in the four domains evaluated. Conclusion: the quality of the documentation of the Nursing process in version II of the system was superior to version I. The efficacy of the system and the effectiveness of the interventions were verified. This study can contribute to the quality of documentation, care management, visibility of nursing actions and patient safety.


Introduction
The Nursing Process (NP) systematizes the clinical evaluation, evidences clinical reasoning, decision-making and clinical judgment about the patient's responses to life problems and processes. It is a methodological tool for the planning of assistance and documentation of the care plan. In addition, it integrates and organizes information, facilitates communication between the members of the interdisciplinary team, and contributes to quality of care and patient safety (1) .
NP appeared in the United States in the 1950s, initially as a guide for nursing students. It was later adopted in the nursing services to give greater autonomy to the profession, to favor holistic care, and to provide continuity of care (2) .
In Brazil, from the work of Horta (1979), the NP was gradually inserted in the undergraduate curricula in Nursing and in the care practice.

From Resolution 358/2009of the Federal Nursing
Council (Conselho Federal de Enfermagem, COFEN), its application (3)(4) has become mandatory in all the environments where professional nursing care occurs.
However, documenting the stages of the NP is still a challenge for health institutions. A survey on the prevalence of documentation in hospitals, clinics and outpatient clinics administered by the Health Secretariat of the State of São Paulo showed that, of the 416 sectors studied, only 288 (69.3%) recorded four stages of the NP (5) .
The NP documentation requires nurses to have knowledge about standardized concepts, rooted in scientific bases of the Nursing Classifications, also known as Standardized Language Systems (SLS) (6) . These systems provide the framework for organizing important concepts about diagnoses, interventions and outcomes.
It even serves as a guide for the NP to be documented in unambiguous language, assists in clinical reasoning, manages care, inter-professional communication and decision-making (7) .
SLSs are a prerequisite for the construction of Electronic Health Records (EHRs), aiming to retrieve information for research studies, statistical analysis, benchmarking, big data, data interoperability between the different health systems and, above all, to ensure continuity and quality of care (6) .
However, finding essential patient data from the perspective of Nursing in the EHRs or in the printed medical records is a major challenge. Research studies show that the quality of Nursing documentation varies from moderate to poor. This includes lack of information, limitations in diagnostic accuracy, inaccurate and redundant documentation (8-10) . Both the EHR and the paper record have problems related to content, process and structure criteria (5,11) .
Nursing can benefit from the development and implementation of EHRs with SLS and Clinical Decision Support Systems (CDSSs). Decision support is a resource that provides access to clinical guidelines and protocols based on scientific evidence. In addition, it can support nurses in NP documentation and in the formulation of accurate diagnoses and effective interventions, which can contribute to highly significant and clinically relevant outcomes for the patient (6,12) .
In this context, the University Hospital of the  (13) .
It is noteworthy that, in the development of this technological tool, there was the active participation of nurses from the HU-USP Nursing Department, EEUSP professors and undergraduate and graduate students.  (13)(14)(15)(16)(17) . It is worth considering that the two versions of the system have mechanisms that prevent the user from progressing in the evaluation if at least one Nursing Outcome, Indicator, Intervention and Prescription activity is not selected for each Diagnosis. These requirements were defined in the system design phase and were Usability is defined as "the extent to which a system, product or service can be used by specific users to attain objectives with effectiveness, efficiency and satisfaction in a specific use context". Effectiveness refers to the "precision and integrity with which users attain specific objectives" (18) .
This study is justified by the need for reliable academic research studies to demonstrate the usability of CDSS in the NP documentation. This is due to the fact that the implementation and deployment studies suggest that functionality and usability affect satisfaction, efficiency and effectiveness in clinical use.
The hypothesis of this study is that the nursing documentation in PROCEnf-USP ® version II is more effective and has better quality when compared with version I of the system.
In this way, the present study was designed with the objective of comparing the quality of the NP documentation in two versions of a clinical decision support system.

Method
A quantitative and quasi-experimental study of the before-and-after type. In the quasi-experimental design, also known as "field experiment", the researcher limits the influence and control over the selection of the study participants. In this type of study, the researcher cannot randomly assign participants and/or ensure that the selected sample is as homogeneous as desirable (19) .
In these surveys, the ability to fully control all the study variables and the implications of the intervention is limited. However, quasi-experimental studies provide fruitful information for advancing research. In addition, in numerous research studies, including those conducted in information systems research, randomization may not be feasible (19) .
The effectiveness of the system was determined documented, and 2=Complete documentation). The minimum score is zero and the maximum is 58 points (20) .
The Nursing Diagnosis subscale as a process comprises 11 items, with a maximum score of 22 points, and addresses the accuracy of the nursing assessment related to Data Collection (patient's history and physical examination) (20) .
The Nursing Diagnosis subscale as a product comprises eight items, with a maximum score of 16 points and addresses the accuracy of the nursing diagnoses when using standardized language or the precision of nursing problems, signs and symptoms when using standardized language (20) .
The Nursing Interventions subscale comprises three items, with a maximum score of six points, and addresses the effectiveness of nursing interventions on the etiology of the nursing diagnosis/problem (20) .
The Nursing Outcomes subscale comprises seven items, with a maximum score of 14 points, and measures the quality of the outcomes of patients sensitive to Nursing (20) .
As recommended in the tutorial for using the Brazilian version of Q-DIO, to compose the sample of the first stage a priority diagnosis was selected, relating it to the interventions and outcomes (20) .
Thus, it was decided to apply the Q-DIO to the Impaired Tissue Integrity nursing diagnosis, as it is first in the ranking of the ten (10) most frequent nursing diagnoses in the Surgical Clinic. This data was obtained from a report generated by Business Intelligence infoView -PROCEnf-USP ® .
According to the Power Test Analysis, it was estimated that, regarding the minimum sample size, to confidently detect the relevance of the intervention effect, the Q-DIO should be applied to at least 10 nursing records at each stage.
For the selection of the sample of version I of the system, a report was issued regarding the hospitalizations that occurred in the Surgical Clinic in the years 2017 and 2018. The sample consisted of 81 nursing records that had a diagnosis of Impaired Tissue Integrity, whose patient's length of stay was at least four days, as recommended by Q-DIO.
Likewise, in order to select the sample for version II of the system, a report was issued regarding the admissions to the Surgical Clinic in the period from November 15 th , 2019 to January 10 th , 2020.The sample consisted of 58 nursing records, which had a diagnosis of Impaired Tissue Integrity, whose length of stay was at least four days. to January 10 th , 2020, referring to the records made in version II of the system.
It should be noted that the records from version I were partially computerized and were collected from the electronic system and from the printed medical records.
The records from version II were fully computerized and collection was conducted online in the electronic system.  (21) . This is a standardization that identifies and conceptualizes processes, areas of knowledge, tools and techniques for project management. According to PMBOK ® , the phases of a project are as follows: Initiation, Planning, Execution, Monitoring and Control, and Closure (21) .
In the Initiation phase, the project and the people involved (stakeholders) were defined, as well as a survey was conducted of the initial risks, which could be evident threats to the project. The main risks identified, which could have a negative impact on the project, were related to human and technological resources. In the Monitoring and Control phase, system errors or "bugs" were identified and forwarded for resolution.
All the corrective actions were monitored and controlled through tests in the system.
In the Closure phase, the follow-ups and pilot implementation were completed. The system is in operation and meeting the requirements of the NP documentation.
The data collected referring to the application of the Brazilian version of Q-DIO were stored in two Excel ® spreadsheets, one for each stage. They were organized and analyzed with the aid of the R software (23) .
The categorical variables of Q-DIO (not documented, partially documented and complete documentation) were described using absolute and relative frequencies.
The continuous and discrete quantitative variables were described by measures of central tendency (mean and median) and dispersion (standard deviation).
In order to estimate the significance of the difference between the means of the pre-and postintervention groups (control and experimental), hypothesis tests were performed: Welch t test with two samples, Brunner-Munzel test, and Wilcoxon-Mann-Whitney test, as appropriate for data distribution. A significance level of 5% was adopted, that is, the results were considered significant if the p-value was      According to Table 3, there is evidence of a difference in the quality of documentation between the two versions of the system in item 20, given that the p-value was below 0.05. There was no statistical difference in the other questions evaluated because they were already close to the saturation level, reaching 100% in the postintervention group.

Discussion
The Brazilian version of Q-DIO has as its main purpose to evaluate the quality of the documentation and the links between Nursing Diagnoses, Interventions and Outcomes (20) . According to the scores obtained in the  (26) .
However, the development of effective systems to document the NP is certainly difficult in the area of health and nursing informatics. Structural problems such as lack of data standardization, safety mechanisms that prevent the user from progressing without completing every item, lack of adequate training and resistance to the adoption of these systems are pointed out as factors that affect quality and usability (26) .
In In the same context, a study that clinically validated the nursing outcome indicators of "Tissue Integrity: Skin and Mucous Membranes" and their conceptual and operational definitions, concluded that the use of indicators with definitions can contribute to a reliable and accurate assessment of tissue integrity and assist in measuring the effectiveness of the nursing care provided (28) .
It is believed that the factors that contributed to the successful implementation of version II of the system are linked to the importance that the professionals attach to the NP in the institution, the efficacy of the system to document the NP and the effectiveness of the interventions related to user training and monitoring and system implementation with new features.
These results corroborate data from a systematic review, concluding that, although the initiatives implemented to improve the quality of documentation in the EHRs are really varied, the most successful interventions can be related to the training of the team and to the implementation of a new reporting system in EHR (29) .
The importance of educational interventions was also verified in a study in which the Q-DIO was used to measure the quality of nursing records at the pre-and post-intervention moments. This process concluded that they were important to improve the quality of nursing care documentation and visibility (30-31) .
As limitations of this study, it is pointed out that the data were collected immediately after the training and implementation of the second phase of the system. It is known that changes in the practice may require more time to develop.
It can be thought of the detection bias, since the researcher works with the system, and may in some This assessment method can be applied in research studies to assess the quality of nursing records and audit processes, enabling adjustments to the NP documentation by means of educational interventions. These analyses will allow for periodic feedbacks to be offered to the nurses, in order to constantly support them in the practice of critical thinking and clinical reflection.

Conclusion
The results of this research confirmed the study hypothesis. According to the total score of the Brazilian version of Q-DIO, the users documented the NP more effectively in PROCEnf-USP ® version II. There was a reduction in the percentage of items not documented in all the subscales evaluated. It was also possible to observe the effectiveness of the interventions, proving that team training and the deployment of a new system, with more functionalities, are factors that contribute to improve the quality of the NP documentation.