Adaptation of software with the nursing process for innovation units

ABSTRACT Objective: To adapt data collection of the Information System software with the nursing process in Intensive Therapy for use in medical and surgical clinic units. Methods: A descriptive study developed in three stages. The first consisted of team training; in the second, the software was applied in clinical practice with 100 patients; and in the third, we analyzed the modifications to be done. Results: There was inter-observer agreement of 91%, followed by application of the software in 100 patients. In the “patient registration” module, it was suggested the exclusion of one item, inclusion of six and modification of four of them. In the anamnesis screens, no items were flagged to be deleted; 26 inclusions and 7 changes were proposed. In the physical examination screens, it was suggested the exclusion of 31 items, inclusion of 26 and modification of 27. Conclusion: Modifying information systems and going through stages methodologically constructed and implemented was important.摘要 研究目的：使重症监护治疗（Intensive Therapy）信息系统软件的数据采集流程适配护理工作规范，以应用于内科与外科临床病房。 方法：本研究为描述性研究，分为三个阶段开展。第一阶段为团队培训；第二阶段将该软件应用于100例患者的临床实践；第三阶段分析待实施的修改方案。 结果：观察者间一致性达91%，随后该软件应用于100例患者的临床实践。在“患者登记（patient registration）”模块中，建议删除1项条目、新增6项条目并修改4项条目。在病史采集界面中，无需要删除的条目，共提议新增26项条目、修改7项条目。在体格检查界面中，建议删除31项条目、新增26项条目并修改27项条目。 结论：对信息系统进行优化，并严格遵循方法论构建与实施各阶段，具有重要意义。