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EXPERIENCE REPORT ON THE CONSTRUCTION OF A MEDICAL RECORD
FOR INTEGRATIVE AND COMPLEMENTARY HEALTH PRACTICES AT
CEPIC/UFT
Ana Clara dos Santos Rodrigues1
Ana Carolina Moreno2
Ana Edith Farias Lima3
Abstract: This experience report describes the development of a specic medical record for
Integrative and Complementary Health Practices at the Center for Integrative and Complementary
Health Practices of the Federal University of Tocantins. The initiative aimed to develop a digital tool
that enables systematic patient registration and integrated monitoring, considering the uniqueness
and comprehensiveness of the care offered by the PICS. The methodology adopted was participatory,
involving the collaboration of health professionals, researchers, and users of this Center, ensuring
the practical and theoretical adequacy of the medical record. As a result, a digital medical record
was structured containing essential information for monitoring integrative therapies, contributing to
the safety, quality, and continuity of care. The experience highlights the feasibility and importance
of implementing specic instruments for integrative care, which can serve as a reference for other
institutions working in the eld.
Keywords: Medical Records. Complementary Therapies. Nursing Process. Health Care. Integrative
1 Nursing student at the Federal University of Tocantins. Intern with a CEPIC-UFT scholarship,
Palmas, Tocantins. Orcid: https://orcid.org/0009-0003-2059-5179
2 Nursing student at the Federal University of Tocantins. Intern with a CEPIC-UFT scholar-
ship, Palmas, Tocantins.
3 Teacher of the Nursing Course and Coordinator of the Center for Integrative and Comple-
mentary Health Practices (CEPIC) at the Federal University of Tocantins. https://orcid.org/0000-
0002-4015-8086
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Medicine.
INTRODUCTION
Integrative and Complementary Health Practices (PICS) have been consolidating themselves
as important care strategies in the Unied Health System (SUS), with a focus on health promotion,
disease prevention, and valuing broader approaches to the health-disease process. In the international
scenario, its insertion dates back to the International Conference on Primary Health Care, in Alma-
Ata (1978), which recommended the incorporation of traditional and complementary medicines into
national health systems (Telesi Júnior, 2016)
In Brazil, this movement was strengthened by the 8th National Health Conference (1986)
and culminated in the creation of the National Policy on Integrative and Complementary Practices
(PNPIC) in 2006 (Brasil, 2006). In line with the recommendations of the World Health Organization
(WHO), the PNPIC has encouraged the safe, effective and quality use of Traditional Chinese Medicine
(TCM) incorporating practices such as acupuncture, meditation, yoga, reiki, phytotherapy, art therapy,
among others (Brasil, 2017; Brazil, 2018).
Evidence indicates that ICPs have contributed positively to pain management, stress and
anxiety reduction, promotion of self-care, and improvement of quality of life, especially in vulnerable
populations. These practices value qualied listening, the therapeutic bond, the integrality of care,
and respect for the subject’s uniqueness (WHO, 2019).
However, despite the progress in public policies and the expansion of the offer of integrative
practices, the absence of specic clinical record instruments represents a challenge. In many services,
conventional medical record models are used — developed for biomedical contexts — that do not
contemplate the subjective and integral complexity of PICS, compromising the quality of the record
and the visibility of care.
At the Center for Integrative and Complementary Practices in Health of the Federal
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University of Tocantins (CEPIC/UFT), this reality was also present. Until recently, a medical record
adapted by nursing students, prepared in 2021, based on conventional records that does not include
a care plan, was used. In view of this, the need to build a new medical record emerged, appropriate
to the specicities of the PICS and the prole of the users served. Considering that the coordination
of the Center is exercised by a nurse and integrative therapist, and that it is also a space for nursing
internships, this process has been guided by the principles of the Systematization of Nursing Care
(NCS), seeking to integrate the logic of integrative practices into the methodological organization of
nursing care.
Nursing, recognized as the science of care, continuously develops and applies strategies
that contribute to the qualication of care, and NCS is an essential organizational instrument in
this process (Santos, 2020). Thus, the present study starts from the following question-problem: how
to develop a specic medical record for PICS that provides a more humanized and qualied care,
overcoming the limits of conventional models and considering the particularities of the public served
by CEPIC/UFT? The general objective is to develop a specic medical record for the registration of
Integrative and Complementary Health Practices that promotes a more humanized and qualied care.
METHODOLOGY
It is an applied research, of a qualitative nature, with descriptive and exploratory stages,
based on the methodological design of action research (Tiolent, 2009). This approach, according to
Kemmis and McTaggart (2003), allows researchers and professionals to act collaboratively in the
identication of needs, development of the medical record and analysis of its applicability in the
context of Integrative and Complementary Health Practices (PICS). The methodology includes the
construction, validation and initial application of the medical record, valuing qualitative aspects —
such as experiences, perceptions and context — and quantitative aspects — such as use, frequency
and analysis of the data collected — ensuring the practical and theoretical adequacy of the tool for the
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context of CEPIC/UFT.
The ideal methodology should contemplate the construction, validation, and possible
initial application of the medical record, valuing both qualitative aspects — such as experience,
perception, and context — and quantitative aspects — such as data use, frequency, and analysis —,
as recommended by Creswell (2014), thus ensuring a comprehensive and integrated approach to the
investigative process.
The theoretical part of the study was built based on the method proposed by Souza, Silva and
Carvalho (2010), which was structured in ve stages:
Research Steps:
1. Situational diagnosis:
- Documentary survey and informal conversation with professionals who work at CEPIC/
UFT to identify the limitations of the current medical record model.
- Analysis of existing records in PICS practices (auriculotherapy, reiki, meditation, etc.).
2. Construction of the Medical Record (medical record):
- Development of a medical record model aimed at recording ICW, considering the integrality
of care, the principles of the National Policy of Integrative and Complementary Practices (PNPIC) and
the Systematization of Nursing Care (NCS).
3. Content validation:
- Application of the Delphi Technique with specialists in PICS, nursing and health information
management to assess the pertinence, clarity and relevance of the proposed items.
4. Pilot application:
- Testing of the medical record in real care at CEPIC/UFT, with participant observation and
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recording of preliminary results.
5. Data analysis:
- The qualitative data of the conversation circles were analyzed using Bardins Content
Analysis.
Population and Sample
Professionals working at CEPIC/UFT (nurses, integrative therapists, interns), health managers
and specialists invited for validation.
For the construction and validation of data and opinions, the Delphi Method was used, an
investigation technique widely used in qualitative and mixed research, with the objective of obtaining
the consensus of a group of experts on a given topic. The method is characterized by an iterative
process in multiple rounds, with the application of successive questionnaires and analysis of the
answers anonymously, allowing the renement of opinions until achieving stability in the answers
(Linstone; Turoff, 2002).
In the present study, two rounds were carried out with a panel of experts in health, integrative
therapies, managers, teachers, etc., previously selected by criteria of expertise and performance in
the area of interest. The answers were analyzed through content analysis, and the levels of agreement
were established based on the percentage of consensus, such as 80%. The preliminary results indicate
that the tool contributes to the qualication of the clinical record and to the generation of data that
may support future analyses on the effectiveness of PICS in the academic and care context of CEPIC/
UFT.
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FINDINGS
FIGURA 1: Identicação
Fonte: Criado pelas Autoras (2025)
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FIGURA 2: Informações sociodemográcas
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FIGURA 3: Termo de consentimento
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FIGURA 4: Exame físico: Avaliação do Estado do paciente
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FIGURA 5: Exame físico encefalopodal, parte 1
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FIGURA 6: Exame físico encefalopodal, parte 2
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FIGURA 7: Exame físico encefalopodal, parte 3
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FIGURA 8: Exame físico encefalopodal, parte 4
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FIGURA 9: Exame físico encefalopodal, parte 5
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FIGURA 10: Exame físico encefalopodal, parte 6
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FIGURA 11: Exame físico encefalopodal, nal e Escala de dor
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FIGURA 12: Inventário de ansiedade de beck
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FIGURA 13: Histórico parte 1
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FIGURA 14: Histórico parte 2
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FIGURA 15: Sinais vitais
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FIGURA 16: Registro do atendimento
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FIGURA 17: Plano de cuidado terapêutico (PCT),parte 1
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FIGURA 18: Plano de cuidado terapêutico (PCT),parte 2
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FIGURA 19: Preferências do paciente para terapias integrativas
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FIGURA 20: Avaliação social e familiar; espiritual
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FIGURA 21: Avaliação espiritual parte 2
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FIGURA 22: Terapias recomendadas parte 1
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FIGURA 23: Terapias recomendadas parte 2
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FIGURA 24: Terapias recomendadas parte 3
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DISCUSSION
ICPs have stood out as strategies capable of expanding the care offered to the population
through multiprofessional and easily accessible approaches. These practices contribute to a more
humanized care, which considers the different dimensions of the individual and promotes a form of
care less focused exclusively on conventional medicine (Aguiar, 2011).
One of the main challenges for the consolidation of ICTs in health services is the need to
review the current care model, which still has a strong inuence of the hospital-centric logic, with a
focus on cure and isolated biomedical interventions. This traditional model often does not contemplate
the complexities involved in the health-disease process, especially with regard to comprehensive care
(Miller, 2010).
Comprehensiveness, as a guiding principle of integrative practices, proposes a broader view
of the subject, considering biological, psychological and social aspects in an interdependent way. In
addition, it advocates the strengthening of teamwork and the articulation between different levels of
care, favoring actions that go beyond the treatment of the disease and include health promotion and
prevention (Rocha et al., 2011).
Since 2006, with the creation of the PNPIC, the SUS has formally recognized and incorporated
practices from different medical and therapeutic traditions. This policy has favored the insertion of
therapeutic approaches recognized by the World Health Organization (WHO) as part of Traditional
Chinese Medicine (TCM), which add value to health care through more comprehensive care, centered
on the person and their autonomy (Brasil, 2006).
These practices also help to break the dichotomy between body and mind, proposing a broader
understanding of health, which includes physical, emotional, mental, and spiritual well-being. According
to Dougans and Ellis (2018), there is an interdependence between the mental and physical states of
the individual, and the balance of both is essential for a healthy life. These views emphasize that no
therapeutic approach is complete by itself, and a respectful dialogue between different knowledges is
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necessary.
Understood under a holistic paradigm, PICS are based on the principle that human beings
are inserted in an energy eld that directly inuences their state of health. In this way, emotional
imbalances, harmful habits, and disordered lifestyle can compromise this ow and, consequently, the
functionality of the body. Healing, in this model, is promoted from the restoration of this harmony,
involving practices that work with vital energy and with the integrality of the being (Dacal et al., 2018).
In the context of CEPIC/UFT, the performance of a multiprofessional team reafrms the
principles defended by the PICS, especially with regard to the promotion of comprehensive, welcoming
and subject-centered care. Practical experience shows how these approaches expand the bond with
users and favor the continuity of care, strengthening qualied listening and the individual’s role in their
health process. In this sense, the systematized record of these interventions, through a medical record
that includes the Therapeutic Care Plan (TCP), proves to be an essential tool to ensure the effectiveness
of the follow-up and the uniqueness of the conducts adopted.
Therapeutic Care Plan
The TCP is a strategic tool that guides the construction of a singular and subject-centered
care (Brasil, 2013). Thus, at CEPIC, its elaboration begins with therapeutic listening carried out by the
coordinating nurse, responsible for welcoming and evaluating newly arrived users, directing them to
the integrative practices that are most appropriate to their needs. From this process, the professionals
of the multiprofessional team collaborate in the formulation of the plan, organizing and articulating
interdisciplinary therapeutic actions that consider the physical, emotional, social and spiritual dimensions
of each individual.
From this perspective, nurses play a central role in using the Nursing Process (NP) as a basis
for planning and executing the TCP, allowing users — with the support of their caregivers — to become
active agents in the management of their condition. The promotion of self-care, the strengthening of
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self-esteem, and the encouragement of participation in therapeutic decisions are fundamental pillars of
this approach (Dorsey et al., 2016; Lennaerts et al., 2017).
The PCT, therefore, must be the result of a collective, dialogical and reective construction
among the various professionals who work at CEPIC/UFT, with emphasis on integrative therapists.
This construction goes beyond clinical diagnoses, contemplating the social determinants of health and
the subjective aspects that make up the life trajectory of each user. Thus, the TCP guides care in a
comprehensive way, covering multiple lines of care and respecting the uniqueness of each person served
(Fernandes; Farias, 2021). In a complementary way, Carvalho (2021) highlights that the articulation
between different specialties is essential so that all dimensions of the person — physical, emotional,
spiritual, and social — are effectively considered and contemplated in the therapeutic plan.
In this context, the consolidation of the TCP in CEPIC highlights the importance of care
practices that integrate different dimensions of care, prioritizing singularity, qualied listening and
the integrality of the subject. Such an approach demands a well-founded, organized and systematic
professional performance, which highlights the relevance of NCS as an essential tool in the construction
of care consistent with the principles of PICS. The NCS, operationalized through the NP, allows nurses
to plan, implement and evaluate personalized interventions, based on clinical diagnoses and identied
needs, promoting ethical, humanized and scientically based care.
Systematization of Nursing Care and its Adaptation in the CEPIC Context
NCS is a process that organizes the professional performance of nurses, allowing the
identication of health and disease situations, as well as nursing care needs. Its main objective is to assist
in the development of interventions that promote health, prevent health problems and favor the recovery
and rehabilitation of the individual (Silva et al., 2015). The NCS is structured through three fundamental
pillars: method, personnel and instruments, which are indispensable for its effective application in the
work environment.
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Within the NCS, the NP is applied, considered a structured method that guides the care
provided. The NP is composed of ve interdependent stages: 1) Data collection (investigation)
identication of relevant clinical information; 2) Nursing diagnosis analysis and interpretation of
the data collected; 3) Planning denition of expected results and interventions; 4) Implementation
execution of the proposed actions; and 5) Evaluation verication of the results and readjustment
of the plan, if necessary (Alfaro-Lefevre, 2014). This process has a holistic and individualized focus,
promoting person-centered care, encouraging self-care, and preventing clinical complications.
The conducts and interventions performed are recorded in the medical record, a fundamental
instrument for the continuity and safety of care. This medical record is also used by integrative therapists,
who describe their conducts and techniques used in each consultation. Thus, the primary purpose of
records is the communication and sharing of information, knowledge, certainties and uncertainties
between professionals from the same eld or from different areas, both synchronously and diachronically
(Gaudin, 2003).
This adapted way of operationalizing the care process is functional and compatible with the
PICS proposal, respecting the principles of comprehensiveness, personalization and interdisciplinarity
of health care. Although it does not rigidly follow the academic molds of the NCS and the NP, the nurses
work at CEPIC/UFT preserves the fundamental pillars of systematized care, using clinical reasoning
and professional judgment as bases for decision-making.
FINAL CONSIDERATIONS
The development of the digital medical record for the registration of PICS in the CEPIC/UFT is
a relevant milestone in the systematization of information and in the qualication of the care provided.
This initiative shows the commitment to the continuous improvement of care, by enabling safer, more
organized and accessible records of the therapies applied.
In addition to favoring the internal organization and evaluation of care, the electronic medical
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record presents itself as a promising tool for other health institutions that seek to integrate ICPs into
their services. The experience of CEPIC/UFT can, therefore, encourage the expansion of the use of
technologies aimed at comprehensive, humanized and evidence-based care.
Future perspectives include the evaluation of the impact of this tool on the effectiveness of
treatments and user satisfaction, contributing to consolidate its importance as an innovative resource in
health care.
It is acknowledged, however, that the present study has limitations, such as the small number
of participants in the focus group and the impossibility of generalizing the results. Even so, the ndings
offer relevant subsidies for the improvement of practice and for the development of new investigations
in the area.
Finally, the articulation between theory and practice, combined with sensitive listening and
the valorization of subjectivities, sustains a transformative, ethical and human-centered care model in
its entirety.
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