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Registos eletrónicos de enfermagem em saúde familiar: Um projeto de melhoria contínua da qualidade
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Abstract(s)
No contexto da Enfermagem de Saúde Familiar, a qualidade dos registos assume um papel
central, pois estes documentam a relação terapêutica entre o enfermeiro e a família. Esta parceria é um
dos princípios fundamentais dos Cuidados de Saúde Primários, onde o enfermeiro de família atua como
um agente promotor do empoderamento familiar, capacitando as famílias para a tomada de decisões
informadas relativas à sua saúde individual, familiar e comunitária.
Este estudo de melhoria contínua da qualidade em enfermagem centrou-se na otimização dos
registos eletrónicos de enfermagem, com especial enfoque nos registos de saúde familiar. O objetivo
principal foi garantir uma documentação mais estruturada e eficaz, promovendo a uniformização dos
registos clínicos e a sua adequação às necessidades da prática assistencial. Como suporte ao estudo,
foi elaborado um manual de procedimentos para a qualidade dos registos clínicos de enfermagem e
um plano digital para o tratamento dos dados.
Conclui-se que a implementação desta ação de melhoria, baseada na avaliação contínua das
práticas assistenciais, demonstra um impacto positivo na qualidade dos cuidados prestados às famílias.
Neste estágio foi evidenciada a importância da investigação, da reflexão e da adaptação às
necessidades em saúde, promovendo ganhos efetivos na qualidade de vida das famílias e na eficácia
dos cuidados de enfermagem. A intervenção centrou-se na capacitação da família como unidade de
cuidados, reforçando a sua autonomia e adaptação funcional, com base numa abordagem sistémica e
fundamentada na evidência científica. Este percurso permitiu ainda desenvolver competências cruciais
para o enfermeiro especialista em saúde familiar.
Palavras-chave – Qualidade; Enfermeiro de Família; Registos Eletrónicos; Melhoria Contínua.
Abstract In the context of Family Health Nursing, the quality of clinical records plays a central role, as they document the therapeutic relationship between the nurse and the family. This partnership is one of the fundamental principles of Primary Health Care, where the family nurse acts as a key agent in promoting family empowerment, enabling families to make informed decisions regarding their individual, family, and community health. This continuous quality improvement study in nursing focused on optimizing electronic nursing records, with particular emphasis on family health records. The main objective was to ensure more structured and effective documentation, promoting the standardization of clinical records and their alignment with the needs of care practice. To support the study, a procedural manual for the quality of nursing clinical records was developed, along with a digital tool for data processing. The implementation of this improvement action, based on the continuous assessment of care practices, showed a positive impact on the quality of nursing care provided to families. During this internship, the importance of research, reflection, and adaptation to health needs was clearly demonstrated, promoting effective gains in families' quality of life and in the efficiency of nursing care. The intervention focused on empowering the family as a unit of care, strengthening its autonomy and functional adaptation, based on a systemic approach and supported by scientific evidence. This journey also enabled the development of key competencies for the specialist nurse in family health nursing. Key words: Quality; Family Nurse; Electronic Records; Continuous Improvement.
Abstract In the context of Family Health Nursing, the quality of clinical records plays a central role, as they document the therapeutic relationship between the nurse and the family. This partnership is one of the fundamental principles of Primary Health Care, where the family nurse acts as a key agent in promoting family empowerment, enabling families to make informed decisions regarding their individual, family, and community health. This continuous quality improvement study in nursing focused on optimizing electronic nursing records, with particular emphasis on family health records. The main objective was to ensure more structured and effective documentation, promoting the standardization of clinical records and their alignment with the needs of care practice. To support the study, a procedural manual for the quality of nursing clinical records was developed, along with a digital tool for data processing. The implementation of this improvement action, based on the continuous assessment of care practices, showed a positive impact on the quality of nursing care provided to families. During this internship, the importance of research, reflection, and adaptation to health needs was clearly demonstrated, promoting effective gains in families' quality of life and in the efficiency of nursing care. The intervention focused on empowering the family as a unit of care, strengthening its autonomy and functional adaptation, based on a systemic approach and supported by scientific evidence. This journey also enabled the development of key competencies for the specialist nurse in family health nursing. Key words: Quality; Family Nurse; Electronic Records; Continuous Improvement.
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Keywords
Auditoria de enfermagem Enfermagem de família Qualidade de cuidados de saúde Registos de enfermagem Registos de saúde eletrónicos Saúde da família Electronic health records Family health Family nursing Nursing audit Nursing records Quality of health care
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