Author(s): Queirós, Carmen ; Silva, Maria Antónia ; Gomes, João ; Neves, Hugo ; Cruz, Inês ; Brito, Alice ; Cardoso, Alexandrina ; Pereira, Filipe Miguel Soares
Date: 2023
Persistent ID: http://hdl.handle.net/10400.26/47166
Origin: Escola Superior de Enfermagem do Porto
Subject(s): Activities of daily living; Electronic health records; Focus groups; Models; Nurses; Nursing; Practice patterns; Standardising nursing terminology
Aims:This study aims to (1) analyse all self-care–related interventions Portuguesenurses documented, (2) determine potential issues that may impair semantic interoper-ability and (3) propose a new set of interventions representing nursing actions regardingself-care that may integrate any HER application.Background:As populations age and chronic diseases increase, self-care concerns rise.Individuals who seek healthcare, regardless of context, need prompt access to accuratehealth information. Healthcare professionals need to understand the information in allplaces where care is provided, creating the need for semantic interoperability withinelectronic health records.Methods:A qualitative descriptive and exploratory study was conducted in two phases:(1) a content analysis of nursing interventions e-documentation and (2) a focusgroup with fifteen registered nurses exploring latent criteria or insights gleaned fromthe findings of content analysis. The COREQ statement was used to guide researchreporting.Results:We extracted 1529 nursing intervention sentences from the electronic healthrecords and created 209 intervention categories. We identified the main issues withsemantic interoperability in nursing intervention identification.Conclusion:According to the findings, nurses cooperate with clients, offering phys-ical aid and encouraging them to overcome functional limitations to self-care taskshampered by their conditions.Implications for nursing policy and health policy:This article provides evidence towarn policy makers against decisions to use locally customised electronic health records,as well as evidence on the importance of policy promoting the adoption of a nursingontologyforelectronichealthrecords.And,asaresult,theharmonisationandeffec-tive provision of high-quality nursing care and the reduction of healthcare costs acrossnations.
