Nursing diagnoses focused on universal self-care requisites

Aims (1) To identify and analyse diagnoses documented by nurses in Portugal within the scope of universal self-care requisites; (2) to determine the main problems with nursing diagnoses syntaxes for semantic interoperability purposes; and (3) to suggest unified nursing diagnoses syntaxes within the scope of universal self-care requisites. Background/Introduction Ageing societies and the increase in chronic diseases have led to significant concern regarding individuals' dependence to ensure self-care. ICNP is widely used by Portuguese nurses in electronic health records for documentation of nursing diagnoses and interventions. Methods A qualitative study using inductive content analysis and focus group: 1. nursing e-documentation content analysis and 2. focus group to explore implicit criteria or insights from content analysis results. Results From a corpus of analysis with 1793 nursing diagnoses, 432 nursing diagnoses centred on universal self-care requisites emerged from the content analysis. One hundred ten nursing diagnoses resulted from the application of new encoding criteria that emerged after a focus group meeting. Conclusion Results reveal that nursing diagnoses related to universal self-care requisites can emphasize the impairment or potentialities of the individuals performing self-care. It also shows a lack of consensus on nominating the nursing diagnoses of people with a deficit in universal self-care requisites, resulting in different diagnoses to express the same needs. Implications for nursing practice Representation of most relevant nursing diagnoses within the scope of universal self-care requisites. Implications for health policy Incorporating standardized language into electronic health records is not enough for improving quality and continuity of care and semantic interoperability achievement. Electronic health records need to work with a nursing ontology in the backend to meet these requirements.