Análise de conteúdo aos diagnósticos e intervenções tegumentares: O primeiro passo para um modelo de cicatrização de feridas

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Wound care specialists are essential to meet the growing need to prevent and treat acute and chronic wounds affecting millions worldwide. Information systems with clinical decision support become essential by collecting, codifying, and storing knowledge, and returning information on-screen to the nurse.Goals: This study aims to identify opportunities for semantic interoperability improvement through the analysis of all diagnoses and interventions used in a public Health Information System related to the integumentary system. Methods: A qualitative descriptive study of nursing diagnoses and interventions data. We selected the Portuguese national Health Information System for data analysis since it was recognized for the progress in terms of information and communications technologies used in the health sector. All nursing diagnoses, interventions, and their relationships available for selection in clinical practice regarding wound healing were analyzed. We performed this research in two phases: (1) Content analysis of nursing diagnoses and interventions, revised by two external experts, and (2) Focus group with Health Information Systems and terminologies experts to discuss and implement contributions to a wound healing clinical model.Results: We matched 66 diagnoses, 171 interventions, and 318 relationships to the integumentary system. Nursing interventions were centered on three action types: performing, determining, and informing. We found unexpected inconsistencies regarding the association between teaching actions and missing knowledge-centered diagnoses. The focus group added an essential perspective on interventions from other domains becoming essential to wound healing. Conclusions: Nurses use standardized language to describe nursing concepts in daily practice. Semantic interoperability is still questionable by persistent changes based on opinions instead of scientific knowledge, with no known public rules or procedures. A qualitative approach allowed for improvements in the concepts used to represent clinical practice and the sentences construction validity.