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Revista de Enfermagem Referência

versão impressa ISSN 0874-0283versão On-line ISSN 2182-2883

Resumo

ESTEVES, Regina Paula Moita  e  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-Maio-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.

Palavras-chave : handover; nursing records; continuity of care; nursing theory.

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