20.500.12556/DKUM-39982 MODELIRANJE ZNANJA ZDRAVSTVENE NEGE ZA POTREBE E - DOKUMENTACIJE NURSING KNOWLEDGE MODELLING FOR E-DOCUMENTATION MODELIRANJE ZNANJA ZN ZA POTREBE E – DOKUMENTACIJE Osnova za elektronsko dokumentiranje podatkov zdravstvene nege je enotna dokumentacija, podatkovni standardi, ustrezno dosegljiva informacijska tehnologija in obstoječa zakonodaja. Pomanjkljivosti na omenjenih področjih so razlog, da se podatki zdravstvene nege še vedno beležijo v papirni in ne v elektronski obliki. V magistrskem delu smo najprej predstavili teorijo zdravstvene nege, ki je osnova za dokumentiranje zdravstvene nege, v nadaljevanju smo predstavili razvoj in obstoječe stanje na področju informatike in dokumentiranja v zdravstveni negi v Sloveniji in na tujem. Osrednji prispevek magistrskega dela predstavlja izdelava in testiranje modela elektronskega zapisa zdravstvene nege na Oddelku za nefrologijo v Univerzitetnem kliničnem centru Maribor. Gre za model elektronskega zapisa zdravstvene nege, ki zajema zbiranje podatkov pri pacientu po temeljnih življenjskih aktivnostih, in obravnavo pacienta po procesni metodi dela, poskusno za tri negovalne diagnoze, s poudarkom na zdravstveni negi nefrološkega pacienta. Prototipno rešitev modela elektronskega zapisa smo testirali v kliničnem okolju s pomočjo mobilnih naprav (tabličnih računalnikov). Na podlagi analize izdelanega modela elektronskega zapisa zdravstvene nege ugotavljamo, da je ta pomembno vplival na komunikacijo, kritično razmišljanje izvajalcev zdravstvene nege, da omogoča pomoč za boljše odločanje pri delu, celostno obravnavo pacienta, ki zajema podatke in obravnavo pacienta po procesu zdravstvene nege in s tem na ustreznejše dokumentiranje zdravstvene nege. Raziskovalno delo odpira številne nove možnosti za nadaljnje razvijanje in izgradnjo enotnega elektronskega zapisa zdravstvene nege v Sloveniji. NURSING KNOWLEDGE MODELLING FOR E-DOCUMENTATION The basis of electronic documentation of nursing care data lies in unified documentation, data standards, adequetely accessible information technology and existing legislation. The flaws in the aforementioned areas are the reason the nursing care data are still being taken down on paper and are not written in the electronic form. In my master’s thesis I have introduced the theory of nursing care, which is the basis for documentation of nursing care, followed by the introduction of the development of the existing situation in the area of informatics and documenting of nursing care in Slovenia and abroad as well. The central part of my master’s thesis represents developing and testing of the model of electronic nursing care record in the Department of Nephrology at the University Medical Centre Maribor. The model I am presenting here is a model of electronic record of nursing care that includes collection of data for a specific patient according to his basic activities in daily living and treats the patient according to the process method of work, which works experimentally for three nursing diagnoses with emphasis on nursing care of a nephrological patient. The prototype solution of the model of electronic record has been tested in medical environment with the help of mobile devices (tablet computers). Based on the analysis of the electronic record model of nursing care that has been built, we can conclude, that it has been influental in communication and critical thinking of the involved in the nursing care, it helps them at better decision making at work, comprehensive treatment of a patient, that includes data and treatment of a patient after a process of nursing care, and by that enables more suitable documentation of nursing care. The research paper gives way to numerous new possibilities in further developing and building a unified electronic record of nursing care in Slovenia. KLJUČNE BESEDE: zdravstvena nega dokumentiranje informatika informacijski sistem nursing care documentation informatics information system true false false [C. Krel] Slovenski jezik Angleški jezik Magistrsko delo/naloga 2013-03-25 10:15:20 2013-05-09 14:54:06 2022-05-12 23:21:00 2021-04-23 03:13:46 2013 0 Maribor 0 0000-00-00 NiDoloceno NiDoloceno NiDoloceno 0000-00-00 0000-00-00 0000-00-00 659.2:004:616-083 1896356 URN:SI:UM:DK:M9NJCFAY MAG_Krel_Cvetka_2013.pdf MAG_Krel_Cvetka_2013.pdf 1 D0F9328E24245094CCE915C63048E753 da716697cbead95ab003228bf66efa5b28370bd5235a4dcff20d52e98de2befa 401e1adc-7c09-11eb-bb7a-00155d0001ca 20.500.12556/dkum/d3702eb1-8d0e-4c88-b458-c7459fa500ef https://dk.um.si/Dokument.php?lang=slv&id=54434 Fakulteta za zdravstvene vede 0 0 0