Objective:

To show the construction of a registry for chronic wound care management framed in the current regulations with NANDA-NIC-NOC taxonomic linkage.

Methodology:

Documentary, descriptive study, with a literature review, showing the construction of nursing records for the management of chronic wound care, finding only one document as a proposal, without describing the construction process, this research was conducted in 2 stages. In stage 1 a documentary review was carried out electronically in platforms of the area, considering through keywords: nursing records, assessment, wounds; combining them with the AND, NOT, OR operators, linking with nursing process and reviewing the legal framework regarding the requirements that a nursing record must contain. In stage 2 a cross of variables with theoretical-ethical-legal foundation of the nursing profession with taxonomic interrelation NANDA-NIC-NOC is performed.

Results:

A nursing clinical record was obtained with 12 dimensions and a total of 95 items, delimited by a legal-legal framework in accordance with Norm-004-SSA, clinical record and the general guidelines for the documentation, evaluation and implementation of nursing care plans.

Conclusion:

The wound care management registry is designed and delimited by the legal framework, with theoretical support to guarantee the quality of nursing care.

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