20.500.12556/DKUM-81974 Izboljšanje kakovosti procesa dokumentiranja v enoti intenzivne nege oddelka za travmatologijo Improving the quality of documenting in the intensive care unit of traumatology department Uvod: V enoti intenzivne nege Oddelka za travmatologijo se obravnavajo poškodbe, ki zahtevajo kompleksno zdravstveno oskrbo. Namen je predstaviti zdravstveno in negovalno dokumentacijo, ki je ključna pri procesni obravnavi pacienta. Metode: V magistrskem delu smo uporabili deskriptivno metodo dela. V teoretičnem delu smo strokovno literaturo iskali s pomočjo različnih podatkovnih baz. V empiričnem delu smo s kontrolnim listom analizirali dokumentacijo, ki se uporablja v izbranem okolju. Kontrolni list smo razdelili na analizo temperaturno terapevtskega lista in na analizo negovalne dokumentacije. Raziskovalni vzorec je predstavljal dokumentacijo 20 hospitaliziranih pacientov, ki so bili obravnavani v enoti intenzivne nege Oddelka za travmatologijo. Rezultati: Ugotovili smo, da je v 45 % pregledanih dokumentacij prišlo do pomanjkanja prostora pri rubrikah: predpisovanje terapije, aplicirana terapija in beleženje vnosa tekočin. Pri analizi negovalne dokumentacije smo ugotovili, da pogosto prihaja do podvajanj vpisanih informacij iz različnih opazovalnih listov na temperaturno terapevtski list. Kadar je dokument beleženje intenzivnega opazovanja pacienta v uporabi, se vpisovanje vitalnih funkcij v 100 % podvaja. Razprava in sklep: Zaradi obsežnosti področja menimo, da bi morali v enoti intenzivne nege Oddelka za travmatologijo imeti prilagojeno tako zdravstveno kot tudi negovalno dokumentacijo. S tem bi lahko dvignili raven kakovosti dokumentiranja v enoti. Introduction: In the intensive care unit of the Traumatology department, injuries that require complex medical care are treated. The purpose is to present medical and nursing documentation, which is crucial in the procedural treatment of the patient. Methods: In the master's thesis we used a descriptive method of research. In the theoretical part, we searched for professional literature with the help of various databases. In the empirical part, we analyzed the documentation used in the selected environment with a checklist. The checklist was divided into the analysis of the temperature therapy sheet and the analysis of the nursing documentation. The research sample represented the documentation of 20 hospitalized patients who were treated in the intensive care unit of the Traumatology department. Results: We found that in 45% of the reviewed documents there was a lack of space in the sections: prescribing therapy, applied therapy and recording fluid intake. In the analysis of nursing documentation, we found that there often occurs a duplication of information entered from different observation sheets to the temperature therapy sheet. When the document recording intensive patient observation is in use, the entry of vital functions is 100% duplicated. Discussion and conclusion: Due to the extensiveness of the field, we believe that the intensive care unit of the Traumatology department should use adapted medical and nursing documentation. This could raise the level of documentation quality in the unit. dokumentacija zdravstvena nega kakovost intenzivna nega documentation nursing care quality intensive care unit true true false [M. Tacer] Slovenski jezik Angleški jezik Magistrsko delo/naloga 2022-06-23 18:04:05 2022-08-29 13:11:31 2022-09-22 09:57:05 0000-00-00 00:00:00 2022 0 Maribor 0 0000-00-00 NiDoloceno NiDoloceno NiDoloceno 0000-00-00 0000-00-00 0000-00-00 005.92:616-083(043.2) 117815043 MAG_Tacer_Monika_2022.pdf MAG_Tacer_Monika_2022.pdf 1 DA2CBB0A0BCB1619A2922A6FC70CCF11 6058992eecc5e27f99e77b4ff5a75e9cae66dca1f1edbedaa2ca8dc1580d3aa8 bb84f80d-0355-11ed-b108-00155d000105 https://dk.um.si/Dokument.php?lang=slv&id=159403 Fakulteta za zdravstvene vede 0 0 0