The Status of Nursing Documentation in Slovenia: a Survey
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Health documentation is a prerequisite for good and sustainable health and social care. It is especially important for patient involvement and their empowerment. A transition from paper to e-documentation together with the electronic patient record should be based on thorough knowledge of the current state of documentation and its usages. The main objective of this paper was to analyse which documents and work methods of documenting processes within nursing are being used within different environments. Furthermore, what are the main reasons for their discrepancies from theoretical approaches and best practices. The analysis is based on a survey carried out on all three levels of healthcare. The survey questionnaire consisted of 12 questions to which responded 286 nursing teams from community health centres, hospitals and retirement homes in Slovenia. The results point to diversity in documenting as well as lack of interoperability. This is reflected in a great number of different documents. All phases of the nursing process were being documented in only 31.8 % of cases. The main reasons for this can be attributed to work organisation, different definitions of data-set requirements and inadequate knowledge by nurses. Survey results pointed out a need for the renewal of nursing documentation towards a more uniform system based on contemporary health technologies.
KeywordsDocumentation Information technology Nursing
- 5.Sewell, J., Informatics and nursing: opportunities and challenges. Wolter Kluwers, Philadelphia, 2015.Google Scholar
- 9.Mazlom, S.R., and Rajabpoor, M., Development and assessment of computerized software for nursing process: a step toward promotion of nursing education and care. Iranian Journal of Medical Education. 14(4):312–322, 2014.Google Scholar
- 15.Häyrinen, K., Lammintakanen, J., and Saranto, K., Evaluation of electronic nursing documentation – nursing process model and standardized terminologies as keys to visible and transparent nursing. Int. J. Med. Inform. 79(8):554–564, 2010. doi:10.1016/j.ijmedinf.2010.05.002.CrossRefPubMedGoogle Scholar
- 18.Lear CL, Walters C Use of electronic nurse reminders to improve documentation: a process improvement for a comprehensive stroke center. CIN [epub ahead of print], 2015Google Scholar
- 19.Remus, S., Kennedy, M.A., Lucas, B.M., and Forbes, T., Nursing documentation in digital solutions. In: Hannah, K.J., Hussey, P., Kennedy, M.A., and Ball, M.J. (Eds.), Introduction to nursing informatics. Springer-Verlag, London, pp. 145–176, 2014.Google Scholar
- 20.Lakbala, P., and Dindarloo, K., Physicians’ perception and attitude toward electronic medica record. Springerplus. 3(63), 2014. doi:10.1186/2193-1801-3-63.
- 21.Ranegger, R., Hackl, W.O., and Ammenwerth, E., Development of the Austrian nursing minimum data set (nmds-at): the third delphi round, a quantitative online survey. In: Hayn, D., Schreier, G., Ammenwerth, E., and Hoerbst, A. (Eds.), eHealth2015 – health informatics meets eHealth. IOS Press, Amsterdam, pp. 73–80, 2015.Google Scholar
- 22.McWay, D.C., Legal and ethical aspects of health information management, 4th edn. Delmar Cengage Learning, Hampshire, 2014.Google Scholar
- 23.Gawande, A., The checklist manifesto: how to get things right. Picador, London, 2011.Google Scholar
- 24.McGonigle, D., and Mastrian, K.G., Nursing informatics and the foundation of knowledge. Jones & Bartlett Learning, Boston, 2014.Google Scholar