Nursing information systems: from documentation as evidence to documentation as a support to the clinical decision making

Abstract

We have witnessed a change in the Health Information Systems (HIS) in what concerns structure, contents and support aiming an optimization of the resources, the best efficiency in cost control and a better management of the quality of services rendered to the citizens. From the standpoint of reformulating the HIS, we can see an evolution in the production of information centered almost exclusively in the need of a documental proof on the care rendered by nurses to the citizens to produce information that can constitute a central resource for their clinical decision making. We aim to describe the evolution of the Nursing Information Systems (NIS), reflect upon the impact of reformulation and implementation of the NIS in Portugal in the development of the nursing practice and reflect upon the impact of the NIS reformulation in the quality of care as well as in Education and Training in the nursing area.