The nursing diagnosis implementation process at the University Hospital of the University of São Paulo

Abstract

More than two decades ago the Nursing Department at the University Hospital of the University of São Paulo implemented the care model called Nursing Care System (NCS), which is comprised of three phases: Background, Evaluation and Nursing Prescription. Since then, it is being developed by the Nursing Department nurses as a guiding instrument for care, teaching and research. Having in mind the automation of the NCS, the nurses began to discuss the need for changes that could speed up the work process with the proposal of implementation of the Nursing Diagnosis as another step of the NCS and with the review of nursing action/interventions. In order to do so, the adoption of a standardized system of the care process language became essential so as to make possible data capture, grouping and classification for analysis and their transformation into information. The present study aims at sharing with other nurses this experience on the implementation process of the Nursing Diagnosis as a second step of the NCS.