The Status of Nursing Documentation in Slovenia: a Survey
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 curren...
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| Veröffentlicht in: | Journal of medical systems 2016-09, Vol.40 (9), p.198-198, Article 198 |
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| creator | Rajkovič, Uroš Kapun, Marija Milavec Dinevski, Dejan Prijatelj, Vesna Zaletel, Marija Šušteršič, Olga |
| description | 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. |
| doi_str_mv | 10.1007/s10916-016-0546-x |
| format | Article |
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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.</description><identifier>ISSN: 0148-5598</identifier><identifier>EISSN: 1573-689X</identifier><identifier>DOI: 10.1007/s10916-016-0546-x</identifier><identifier>PMID: 27460383</identifier><language>eng</language><publisher>New York: Springer US</publisher><subject>Documentation - standards ; Electronic Health Records ; Emerging Technologies for Connected Health ; Health Care Surveys ; Health Informatics ; Health Sciences ; Information technology ; Medicine ; Medicine & Public Health ; Nursing ; Nursing Staff, Hospital ; Polls & surveys ; Slovenia ; Statistics for Life Sciences ; Systems-Level Quality Improvement</subject><ispartof>Journal of medical systems, 2016-09, Vol.40 (9), p.198-198, Article 198</ispartof><rights>Springer Science+Business Media New York 2016</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c372t-d38d459307e6c0dedeb7eb845c61338a9af7b47ba957703cda4bd65108cb09ea3</citedby><cites>FETCH-LOGICAL-c372t-d38d459307e6c0dedeb7eb845c61338a9af7b47ba957703cda4bd65108cb09ea3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s10916-016-0546-x$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s10916-016-0546-x$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,780,784,27924,27925,41488,42557,51319</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/27460383$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Rajkovič, Uroš</creatorcontrib><creatorcontrib>Kapun, Marija Milavec</creatorcontrib><creatorcontrib>Dinevski, Dejan</creatorcontrib><creatorcontrib>Prijatelj, Vesna</creatorcontrib><creatorcontrib>Zaletel, Marija</creatorcontrib><creatorcontrib>Šušteršič, Olga</creatorcontrib><title>The Status of Nursing Documentation in Slovenia: a Survey</title><title>Journal of medical systems</title><addtitle>J Med Syst</addtitle><addtitle>J Med Syst</addtitle><description>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. 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| identifier | ISSN: 0148-5598 |
| ispartof | Journal of medical systems, 2016-09, Vol.40 (9), p.198-198, Article 198 |
| issn | 0148-5598 1573-689X |
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| source | MEDLINE; SpringerNature Journals |
| subjects | Documentation - standards Electronic Health Records Emerging Technologies for Connected Health Health Care Surveys Health Informatics Health Sciences Information technology Medicine Medicine & Public Health Nursing Nursing Staff, Hospital Polls & surveys Slovenia Statistics for Life Sciences Systems-Level Quality Improvement |
| title | The Status of Nursing Documentation in Slovenia: a Survey |
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