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But don t let all your secrets out from the start. Inception, Elaboration, Construction, Transition adopting a project management model based on the Project Management Institute PMI 1with sets forth a set of project management guidelines, orientations and practices that is adopted as a software engineering standard.
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Hence, a set of best software development practice principles were adopted, starting from adaptations of the set of processes related to the RUP Rational Unified Process In the Inception phase, the scope of the project is approved and defined, the resources needed for its execution are estimated and expected problems and benefits are identified. In the Elaboration phase, the goal is to analyze the problem domain, in the attempt to complement the survey of usage case documentation.
This phase includes system data modeling, that is, when the system is actually programmed. The Construction phase represents system development itself, with a view to refining the requisites, building and testing its components. In this phase, functional prototypes of the system can be used.
The Transition phase covers the introduction of the new information system in all environments, user training for usage, integration with other information systems and assessment of user satisfaction These pilot units were chosen due to the future easy replication of the obtained results in other hospitalization Units.
To develop the project, a multiprofessional workgroup was set up, including faculty members and baccalaureate nurses, researchers from varied knowledge areas related to clinical care, care process management and health informatics, as well as baccalaureate and graduate nursing students.
This permitted a broad view of the project dimensions and the incorporation of specific technological advances from each knowledge area. In the detailing phase for data modeling and system development, the HU-USP hired a company that had already developed other systems for the Institution and the DE indicated the Director of the Clinical Nursing Division to be responsible for presenting and negotiating on the Management Group's decisions with the hired company and with the Informatics Sector at the HU-USP.
Use cases were validated and the system was approved during meetings between the Management Group, technicians from the hired company and a representative from the HU-USP Informatics Sector. As other DE areas are expected to put the documentation system in practice, articulation was sought with the Directors and representatives from the Maternal-Infant and External Patient Nursing Division, with a view to their collaboration in the organization of materials for the databases.Poker - Reglas basicas - Valor de las cartas y jerarquia de manos
Activity timetables were agreed upon between the Management Group and the DE Director, with a view to follow-up of the computerization project and joint work for the creation of the knowledge bases needed to operate the system. The nurses developed manual instruments to document the diagnoses, nurses' orders and progress notes 1which outlined the construction of the system. Users can choose two different routes, depending on their need, and can either enter the clinical assessment data and visualize the nursing diagnosis hypotheses generated by the system or directly choose the nursing diagnoses.
The phases users have to go through follow clinical reasoning, ranging from interview and physical exam data documentation until the nurses' orders documentation. To start documenting the assessment, users have to enter the real in the professional environment or fictitious in the academic environment patient's registration number. Medical Clinic, Surgical Cliniccategory E. Male Adult, Female Adult and the type of assessment E. The answers given to the Questionnaires will automatically generate Nursing Diagnosis hypotheses.
When choosing one or more of these Diagnoses, users should complete documentation on the Defining Characteristics and Related or Risk Factors the patient presents.
Users should obligatorily choose at least one Outcome for each Diagnosis. If not, they will not be able to move on in the system.
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The system permits including other Outcomes besides automatic suggestions. Users have to choose at least one Intervention for each Outcome.
The system permits the inclusion of other Interventions besides those indicated. It allows users to include other Activities not linked with the selected Intervention. Additional information can be added to an activity, such as frequency and application sites for example.
Users can indicate the patient's body site the activity refers to, using an iconographic scheme corresponding to the body regions.
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The system summarizes the user's assessment, including the following data: Users can request the following Reports: Answers related to the 28 Questionnaires. The Inception phase focused on the system and involved the establishment of basic requisites. Therefore, the Clinical Nursing and Nursing Management Minimum Data Sets were surveyed and questionnaires were elaborated to collect Nursing Diagnosis data for clinical and surgical patients 1.
The clinical assessment documentation structure was organized according to a knowledge base, supported by the definitions of the diagnoses and their components, following the taxonomy of domains, classes and diagnoses proposed by the unification of the NANDA-I, NIC and NOC structures This knowledge base should serve as a documentation guide, capable of generating a list of the most probable nursing diagnoses according to the assessment data documented in the system.
For this purpose, the automatic method adopted for recording the patient's nursing assessment was the development of a branched questionnaire, in which nurses are led to different questions that can be customized for each patient 1. The PROCEnf-USP guides nurses to answer a set of questions whose answers can be tabulated, leading to a probable set of diagnoses and supporting the generation of diagnostic hypotheses.
The assessment, analysis and choice of the defining characteristics and applicable related and risk factors, structured in the database of probable diagnoses, allows nurses to decide on what set of diagnoses best pictures the patient's situation at the time of hospitalization, according to their clinical judgment.
In this phase, hypotheses are tested and finally, the best diagnosis in the diagnostic process is chosen. Besides the questionnaires for the 28 NNN structure classes, three further questionnaires were created, which are obligatory when a patient is admitted social and demographic data, health events and vital signs.
Once documented, data from these three additional questionnaires that are relevant for any NNN class are automatically copied to the class es they belong to. With regard to the scales, the system automatically calculates the scores and establishes hypotheses on the relevant diagnoses.
The Nursing Management Group defined the link between the answers and the diagnoses by consensus, based on the NANDA-I 13 taxonomy, the theoretical framework from the reference areas and the nurses' clinical experience. The rule was adopted that it was necessary that all diagnoses could show up in the hypotheses at least once as a result of the answers given to the included questions. Hence, after the full or partial data documentation, the system itself presents that diagnostic hypotheses that were automatically generated calculated diagnoseswhich nurses have to confirm or reject, guaranteeing that they take the final decision about the determination of the diagnosis.
Whenever pertinent, questions with the same wording and the same possible answers were repeated in more than one questionnaire classas recursive questions.
Once documented in one class, those recursive questions are automatically documented in the other class es they are present in. This avoids duplicating efforts without violating the structure defined to organize the questionnaires. To support the choice of outcomes and nursing interventions, the possible connections between diagnoses and expected outcomes and between outcomes and interventions that are pertinent to the HU-USP's context were inserted in the system. The diagnoses and expected outcomes were included in the links according to their titles and the interventions were linked according to the activities recommended by the NIC.
Links were based on available literature and on reflections about clinical nursing practice at the Institution. In the Elaboration phase, the software was selected that would be used to develop the system.