Protocolo operacional padrão para registro de enfermagem no prontuário eletrônico do cidadão

Abstract

Primary Health Care (PHC) is the gateway to health actions and services of the Unified Health System (UHS). In order to provide information management and improve work processes, the e-SUS APS system was implemented, which includes the Citizen Electronic Medical Record (CEMR) tool. Practice records in PHC are guided by attributes that make up the ProblemOriented Clinical Record and its main tool is the SOAP method, which organizes the progress of consultations in a practical and standardized way. Nursing records are essential for the work process, but studies point to weaknesses in this practice, especially when combined with the use of the Nursing Process (NP). Therefore, it is essential that professionals are oriented and trained to deal with the computerization of records in PHC and with the use of the NP. Therefore, we sought to develop an operational technology for nursing records in the PEC of PHC. To this end, a methodological study was carried out to develop a Standard Operating Protocol (SOP), divided into two stages: 1) Scope Review and 2) Development of the SOP. The JBI method was used for the review, following the following stages: 1) Identification of the research question; 2) Identification of relevant studies; 3) Selection of studies based on eligibility criteria; 4) Data mapping; 5) Grouping and reporting of results. The descriptors “Nursing Process”, “Primary Health Care” and “Electronic Health Records” were used, and were searched in the following databases: Pubmed, BVS, Scopus, ScienceDirect, Embase and Web of Science. The second stage consisted of the following steps: 1) Definition of objectives; 2) Literature review; 3) Planning; 4) Development of the SOP. Nine studies were included in the scoping review, which indicated that the main limitations of electronic health records (EHR) in PHC were “Insufficient and inadequate training” and “Time/work overload”, while the main facilitator was “Agility in care”. These factors were considered as defining and supporting criteria for the development of the protocol. It is concluded that the construction of operational technology serves as a guide to qualify and standardize electronic records through the documentation of the legally established stages of the nursing process in PHC, especially in the context of the Electronic Citizen Record.