Historia clínica electrónica en las unidades de cuidados intensivos: validación del instrumento sobre la percepción y satisfacción del personal de enfermería

Introduction: When providing healthcare, it is necessary to record treatment activities in the patient’s electronic medical records, which serves as a tool that impacts several tasks, including those performed in intensive care units. Any failure of these electronic systems has a direct impact on the delivery of healthcare. This study is aimed to assess the perception of the use of electronic medical records and satisfaction levels among intensive care nurses, as well as to evaluate a questionnaire instrument for this purpose. Materials and Methods: A quantitative cross-sectional study was conducted in Sao Paulo. The instrument used for collection was prepared by the authors, which was also validated in terms of appearance and content. Categorical variables were compared using Fisher’s exact test and numerical variables were compared using the Kruskal-Wallis test. Results: 75 nursing professionals, mostly women and classified as nurse technicians, participated in this study. The majority of the participants considered that electronic medical records were easy to use, indicated that they had sufficient knowledge about the management of electronic medical records, noted that the number of computer in the hospital was insufficient, and stated that both patient and healthcare team safety had improved after using the patient’s electronic medical records. Male nurses found it more difficult to use this tool. Conclusions: Electronic medical records were found to be easy to use, while the main difficulties are related to their functionality, especially by male nurses. How to cite this article: Costa, Daiane Vieira Medeiros; Gomes, Vanessa Rossato; Godoi, Ana Maria Limeira de. Prontuario eletronico em terapia intensiva: validacao de instrumento sobre percepcao e satisfacao da enfermagem. Revista Cuidarte. 2021;12(2):e1332. http://dx.doi.org/10.15649/cuidarte.1332