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Informatización del proceso de atención en enfermería en un hospital de alta complejidad

Departamento de Enfermería, Hospital Italiano de Buenos Aires, Argentina; Residencia de Informática Médica, Hospital Italiano de Buenos Aires, Argentina; Departamento de Información Hospitalaria, Hospital Italiano de Buenos Aires, Argentina

ABSTRACT Resumen-Los sistemas de información en salud requieren para ser completos, poseer todos los datos provenientes del correcto registro del proceso de atención en enfermería. Existen diferentes experiencias internacionales donde el registro electrónico mejora la completitud de los datos en comparación al modo manual. El presente trabajo describe la experiencia obtenida a partir del relevamiento para el desarrollo de un sistema de registro de la actividad de enfermería en el marco de una historia clínica electrónica. Palabras-claves: Historia clínica electrónica, Proceso de enfermería, Documentación en enfermería. Abstract -Health Information Systems must include all the data from an accurate record of the nursing care process to be complete. Different international experiences illustrate that the use of electronic records provide for more complete data collection in comparison to manual methods. The present work describes the assesment for the development of a system of nurse activity records within the framework of electronic medical records.

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May 21, 2014