Design of a nursing clinical record for ambulatory care in neurology

Lizeth J. Casanova-Quintana, Facultad de Enfermería y Obstetricia, Universidad Nacional Autónoma de México, Ciudad de México, México

The increasing number of procedures performed in the ambulatory setting has created the need to strengthen clinical surveillance and continuity of care through standardized nursing records. These records constitute an essential tool for documenting patient outcomes, facilitating communication among the multidisciplinary healthcare team, and ensuring patient safety and quality of care throughout the healthcare process. The analysis focused on diagnostic and therapeutic ambulatory procedures performed at a specialized neurology and neurosurgery institute, including neuroimaging studies, endovascular therapy, lumbar puncture, and outpatient intravenous treatments. A documentary literature review was conducted using the PRISMA methodology and the PICO framework to guide the search and selection of scientific evidence related to nursing clinical records, ambulatory care, patient safety, and clinical communication models. The evidence made it possible to identify the clinical, administrative, and patient safety components required for the design of a nursing clinical documentation instrument, as well as to select the SOAP communication model as the framework for structuring the documentation and strengthening continuity of care. The review provided the scientific basis for the design of a proposed nursing clinical documentation instrument for patients undergoing ambulatory procedures by integrating evidence related to clinical documentation. This proposal provides a foundation for future research aimed at its validation and implementation, with the potential to strengthen nursing practice and serve as a reference for other institutions providing specialized ambulatory care.

Keywords: Nursing instrument. Ambulatory care. Patient safety. Invasive procedures. Clinical communication.