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Revista de Enfermagem Referência
versión impresa ISSN 0874-0283versión On-line ISSN 2182-2883
Resumen
ESTEVES, Regina Paula Moita y AMARAL, António Fernando Salgueiro. Content of shared information: From discourse to documentation in clinical decision-making in nursing. Rev. Enf. Ref. [online]. 2023, vol.serVI, n.2, e22006. Epub 29-Mayo-2023. ISSN 0874-0283. https://doi.org/10.12707/rvi22006.
Background:
Quality of care depends on the information shared orally during shift handovers and documented in the clinical records.
Objective:
To analyze the verbal and written information shared in shift handovers and its impact on clinical decision-making in nursing and the continuity of care in a pediatric emergency ward, as well as identify the emerging paradigm for care.
Methodology:
Qualitative approach, based on Yin’s case study process, using three methods: transcription of the shift handover, documented process, and process carried out by the expert.
Results:
The results show increased sharing of information about unintentional body processes, especially in oral transmission. Although documented data includes more detailed information about adaptive processes, it is incipient for a structured and intentional conception of nursing care.
Conclusion:
The verbal and written information shared in shift handovers mainly focuses on the disease rather than the individual as a whole. Autonomous nursing information does not address the dimension of the person, the human responses to transitions, and the life processes.
Palabras clave : handover; nursing records; continuity of care; nursing theory.