Keywords
Intensive care units
Nursing process
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Abstract
Objective: To describe the barriers and facilitators encountered by intensive care unit nurses in performing effective nursing records/documentation through electronic medical records. Methods: Quantitative, descriptive-exploratory and cross-sectional study, in which 15 nursing professionals participated. Data were collected using a statistical software IBM Statistical Package for the Social Sciences 20, with a significance level of 0.05. Data were expressed as mean and standard deviation, frequency and percentage. Results: The main barriers to electronic recording of the Nursing Process from the nurses' perspective were the insufficient number of nursing professionals and factors associated with the infrastructure of the care unit to perform the activity. The electronic medical record was identified as the main facilitator for nursing records. Conclusion: Knowing the barriers and facilitators for nursing records in the electronic medical record allows for the promotion of actions and support measures that can assist nurses in performing appropriate records.
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