pregled literature
Marija Pogačar (Author), Renata Vettorazzi (Reviewer), Andreja Mihelič Zajec (Mentor), Jelena Ficzko (Co-mentor)

Abstract

Uvod: Standardizirana terminologija je ključnega pomena za uvedbo enotne elektronske dokumentacije v zdravstvu. Omogoča natančno komunikacijo z odpravljanjem in zmanjševanjem dvoumnosti jezika, kar posledično izboljša dokumentacijo. Integriran model standardne terminologije lahko pripomore k boljši komunikaciji in usklajenemu načrtovanju zdravstvene obravnave s strani vseh zdravstvenih delavcev. Namen: Z diplomskim delom bomo raziskali poznavanje standardizirane terminologije med medicinskimi sestrami in kakšen vpliv ima standardizirana terminologija na elektronsko dokumentacijo. Raziskali bomo tudi vpliv informatike za potrebe dokumentacije v zdravstveni negi. Metode dela: Uporabili smo deskriptivno raziskovalno metodo, narejen je sistematični pregled literature. Časovni okvir objav iskane literature je od leta 2006 do 2017. Literaturo smo iskali v slovenskem in angleškem jeziku v podatkovnih bazah CINAHL (Cumulative Index of Nursing and Allied Health Literature), Medline (Medical Literature Analysis and Retrieval System Online), Google Scholar in COBIB.SI. Identificirali smo 327 enot, v analizo smo vključili 26 člankov. Rezultati: Na področju standardizirane terminologije se v Sloveniji zelo malo raziskuje. V tujini so dokumentacijo v zdravstveni negi razvijali z uporabo informacijsko-komunikacijske tehnologije v poenotenih elektronskih sistemih. V podporo so jim bili strokovnjaki s področja informatike. Tuji raziskovalci menijo, da je standardizirano terminologijo potrebno uporabiti v elektronskem dokumentiranju, saj povečuje varnost pacientov, zmanjšuje možnost napake in preprečuje različne interpretacije. Razprava in sklep: Uporaba standardizirane terminologije je dvignila kakovost dokumentacije v zdravstveni negi. V zdravstveno nego bi bilo smiselno vključiti standardizirano terminologijo v kombinaciji z elektronsko dokumentacijo. Avtorji z raziskavami potrjujejo, da se zdravstveni delavci otepajo dela z računalnikom, hkrati nimajo zadostnega znanja informatike in uporabe informacijsko-komunikacijske tehnologije. Z uvedbo standardne terminologije v zdravstveni negi bi močno povečali kakovost komunikacije v zdravstvu, kar vodi k boljši zdravstveni negi pacientov.

Keywords

diplomska dela;zdravstvena nega;terminologija;elektronski zdravstveni zapisi;dvoumja;informatika;

Data

Language: Slovenian
Year of publishing:
Typology: 2.11 - Undergraduate Thesis
Organization: UL ZF - University College of Health Studies
Publisher: [M. Pogačar]
UDC: 616-083
COBISS: 5328491 Link will open in a new window
Views: 1367
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Other data

Secondary language: English
Secondary title: Standardized terminology as a prerequisite for high-quality electronic nursing documentation
Secondary abstract: Introduction: Standardized terminology is key to the introduction of a uniform electronic documentation in healthcare. It provides accurate communication by eliminating and reducing the ambiguity of the language, which in turn improves the documentation. An integrated model of standard terminology can help to better communicate and coordinate the planning of healthcare treatment by all health professionals. Purpose: This diploma thesis will explore the knowledge of standardized terminology among nurses and the impact of standardized terminology on electronic documentation. We will also explore the impact of informatics on documentation requirements in the nursing care. Methods: We used a descriptive research method, and also, a systematic review of literature was made. The period of publication of the searched literature was from 2006 to 2017. We searched for literature in Slovene and English in CINAHL databases (Cumulative Index of Nursing and Allied Health Literature), Medline (Medical Literature Analysis and Retrieval System Online), Google Scholar and COBIB. SI. We identified 327 units and 26 articles were included in the analysis. Results: There is little research in the field of standardized terminology in Slovenia. In the rest of the world, health care documentation was developed using information and communication technology in unified electronic systems. They were supported by experts in the field of informatics. Foreign researchers believe that standardized terminology should be used in electronic documentation, because it increases patient safety, reduces errors and prevents various interpretations. Discussion and conclusion: The use of standardized terminology has raised the quality of documentation in nursing care. For nursing care it would be useful to include standardized terminology in combination with electronic documentation. Researchers confirm that healthcare professionals are refusing to work with their computers, while not having sufficient knowledge of information technology and the use of information and communication technology. By introducing standard terminology in nursing, the quality of communication in the health sector would greatly increase, leading to better patient nursing care.
Secondary keywords: diploma theses;nursing care;terminology;electronic health record;ambiguities;informatics;
Type (COBISS): Bachelor thesis/paper
Study programme: 0
Thesis comment: Dipl. delo (bolonjski študij), Univ. v Ljubljani, Zdravstvena fak., Oddelek za zdravstveno nego
Pages: 34 str.
ID: 10910850