diplomsko delo
Aida Hadžić (Author), Renata Vettorazzi (Reviewer), Martina Bizjak (Mentor), Marjanca Kovše (Co-mentor)

Abstract

Uvod: Dokumentacija je pomembna na vseh področjih, na področju zdravstva pa še toliko bolj. Za celosten pristop in kakovostno obravnavo pacienta skozi proces zdravljenja je pomembna povezanost dokumentacije zdravstvene nege z drugimi dokumenti. Zato sta poleg papirne oblike dokumentacije potrebni razvijanje in implementiranje elektronske oblike dokumentiranja. Namen: Namen diplomskega dela je predstaviti elektronsko vodeno dokumentacijo zdravstvene nege. Predstaviti stališča medicinskih sester o dokumentiranju v zdravstveni negi, raziskati kateri dejavniki vplivajo na implementacijo kliničnega informacijskega sistema, primerjati papirno in elektronsko dokumentacijo, predstaviti izkušnje uporabe elektronske dokumentacije, ter narediti SWOT-analizo elektronsko vodene dokumentacije zdravstvene nege. Metode dela: Uporabljena je deskriptivna metoda dela, s kritičnim pregledom izbrane slovenske in tuje literature s področja dokumentacije in dokumentiranja zdravstvene nege. Zajema pregled domače in tuje znanstvene, strokovne literature, zbornikov in strokovnih člankov. Časovni okvir iskanja literature je postavljen od novembra 2019 do marca 2020. Na temelju vključitvenih in izključitvenih meril je v rezultate vključenih 14 enot literature. Rezultati: Za dokumentiranje se v povprečju porabi ena ura (12,5 % delovnega časa) v delovni izmeni ne glede na raven izobrazbe. Največji vpliv na implementacijo imajo človeški dejavniki, vodilni med njimi je računalniško predznanje. Klinični informacijski sistem predstavlja zadovoljstvo, uporabnost, udobje, ustreznost in sprejemljivost. Prihrani čas za dokumentiranje. Razprava in zaključek: Dejstvo je, da računalniki in informacijska tehnologija postajajo neizbrisni in zelo pomembni v zdravstvu, tudi na področju zdravstvene nege. Elektronska dokumentacija zdravstvene nege poenoti tako obliko dokumentov, zapisov kot tudi izrazoslovje. Glavna povezava oziroma razlika med papirno dokumentacijo in elektronsko vodeno dokumentacijo zdravstvene nege, ki je opisana v vseh enotah analizirane literature, se kaže v urejenosti in grupiranju podatkov. S pomočjo elektronsko vodene dokumentacije zdravstvene nege medicinske sestre lažje, hitreje in kakovostneje zbirajo, beležijo in izmenjujejo podatke o pacientu, evalvirajo že izvedene postopke in lažje načrtujejo nadaljnje zdravstveno-negovalne postopke.

Keywords

diplomska dela;zdravstvena nega;dokumentacija zdravstvene nege;elektronska dokumentacija zdravstvene nege;klinični informacijski sistem;

Data

Language: Slovenian
Year of publishing:
Typology: 2.11 - Undergraduate Thesis
Organization: UL ZF - University College of Health Studies
Publisher: [A. Hadžić]
UDC: 616-083
COBISS: 36422915 Link will open in a new window
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Other data

Secondary language: English
Secondary title: Electronic documentation management in healthcare
Secondary abstract: Introduction: Documentation is important in different areas and fields of work, but especially so in healthcare. If we want to achieve an overall approach and quality treatment of the patient then it is crucial to connect nursing documentation with other relevant data of the patient. In everyday work paper documentation is still a regular feature but development and implementation of electronic documentation are becoming more and more important. Purpose: Our goal was to present the meaning of documentation in nursing healthcare, to present the views of nurses on documentation in nursing, to investigate which factors influence the implementation of the clinical information system, to compare paper and electronic documentation, to present the experience of using electronic documentation and make SWOT analysis of electronic nursing documentation. Methods: We used descriptive methodology, with a critical overview of Slovene and foreign literature regarding documentation in general, and particularly in the field of nursing/healthcare. Listed is the summary of Slovene and foreign scientific literature, papers and articles. The time frame of processing sources is November 2019 to March 2020. On the base of established criteria, 14 units of literature are used as references. Results: Approximately one hour is spent on managing documentation - this is 12,5% of the shift work hours, independent on the level of education. The biggest influence on the implementation of electronic nursing documentation is the human factor, especially computer competence. Electronic health record is a timesaving, useful, acceptable and adequate tool for quality care of the patient. Discussion and conclusion: The fact is that computers and information technology have become an integral part of the healthcare and nursing system. Electronically managed documentation enables the standardization of forms, terminology and data input. The main benefit of electronic health documentation as compared with handwritten medical records is the accuracy and legibility. Medical workers can access the relevant data of the patient quickly and effectively, make notes, share information and design the most appropriatefuture treatments.
Secondary keywords: diploma theses;nursing care;nursing documentation;electronic nursing documentation;healthcare information system;
Type (COBISS): Bachelor thesis/paper
Study programme: 0
Embargo end date (OpenAIRE): 1970-01-01
Thesis comment: Univ. v Ljubljani, Zdravstvena fak., Oddelek za zdravstveno nego
Pages: 31 str.
ID: 12130157