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Title:SISTEMSKI PRISTOP K OBLIKOVANJU E-DOKUMENTACIJE ZDRAVSTVENE NEGE
Authors:ID Rajkovič, Uroš (Author)
ID Zupančič, Jože (Mentor) More about this mentor... New window
ID Šušteršič, Olga (Comentor)
Files:.pdf DR_Rajkovic_Uros_2010.pdf (1,45 MB)
MD5: 830F15433015DCF59A0AC7DA3AE112A9
PID: 20.500.12556/dkum/d148bd0b-4935-462f-b635-812b168948df
 
Language:Slovenian
Work type:Dissertation
Organization:FOV - Faculty of Organizational Sciences in Kranj
Abstract:Učinkovito dokumentiranje procesov zdravstvene nege je eden ključnih problemov zdravstvene nege kot temeljne sestavine celovitega sistema zdravstvenega varstva. Ustreznost dokumentiranja se nanaša na obvladovanje velikega števila zahtevnih informacij, ki jih medicinska sestra srečuje pri načrtovanju, izvajanju in vrednotenju zdravstvene nege. Gre za pripomoček pri ocenjevanju zdravstvenega stanja pacienta, pri odločanju o negovalnih diagnozah in intervencijah ter pri ocenjevanju rezultatov zdravstvene nege. Pri tem je smiselno izrabiti možnosti, ki jih ponuja sodobna informacijska in komunikacijska tehnologija ne le v administrativnem, ampak tudi v kognitivnem smislu. Osrednji prispevek doktorske disertacije predstavlja model e-dokumentacije zdravstvene nege, ki na osnovi sistemskega pristopa informatizira proces le-te, tako s stališča celovite obravnave pacienta, kot tudi spremljanja procesa samega v smislu zagotavljanja njegove kakovosti. Model zajema interaktivno uporabo ocene zdravstvenega stanja pacienta, ki je medicinski sestri v pomoč pri odločitvah, ki jih mora sprejeti pri svojem delu, obenem pa zmanjšuje možnost napak. Model je prototipno implementiran, preizkušen v praksi in kritično ovrednoten. V disertaciji je najprej predstavljen sistem zagotavljanja zdravstvene nege s posebnim poudarkom na procesni metodi dela in njenih fazah. Temu sledi poglavje o sodobnih načinih dokumentiranja. Predstavljen je razvoj dokumentiranja, zapis o pacientu in klasifikacije v zdravstveni negi. Poglavje se zaključi s pregledom nekaterih rešitev po svetu. Analiza obstoječe negovalne dokumentacije v Sloveniji je izvedena na osnovi anketne analize na vseh treh ravneh zdravstvene dejavnosti, kar je podrobno opisano v naslednjem poglavju. Sledi predlagani model e-dokumentacije, ki je najprej predstavljen s strani podatkovnega modela, za tem pa še s strani programske rešitve. Poseben poudarek je na funkcionalnostih, in sicer od zajemanja podatkov, njihove celovite obdelave, uporabe modelov, do predstavitve rezultatov v pogledu dodane vrednosti, ki jo rešitev prinaša v dokumentiranje in izvajanje zdravstvene nege. Posebno poglavje je posvečeno testiranju rešitve v praksi. Rezultati testiranja so povzeti v obliki analize SWOT. Pričujoče raziskovalno delo odpira številne možnosti za nadaljnje raziskave, kot je npr. uporaba ekspertnega znanja za pomoč pri odločanju, ocenjevanje tveganj, zmanjšanje števila neželenih dogodkov in aktivnejše vključevanje pacienta v procese zdravljenja.
Keywords:organiziranje, zdravstvena nega, e-dokumentacija, sistemski pristop, proces zdravstvene nege
Place of publishing:Kranj
Year of publishing:2010
PID:20.500.12556/DKUM-13827 New window
COBISS.SI-ID:251133184 New window
NUK URN:URN:SI:UM:DK:QE4ZXPBN
Publication date in DKUM:13.09.2010
Views:10517
Downloads:2248
Metadata:XML DC-XML DC-RDF
Categories:FOV
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Secondary language

Language:English
Title:SYSTEM APPROACH TO DEVELOPMENT OF E-NURSING DOCUMENTATION
Abstract:Effective documentation of nurses' work is one of the key problems found in nursing care in the broader context of the health care system. Effectiveness refers to managing large amounts of demanding information a nurse is faced with during the stages of planning, implementation and evaluation of nursing care. It is a tool for evaluating patient's health status, deciding on nursing diagnoses and interventions, as well as a tool for evaluating nursing outcomes. In this respect contemporary information and communication technology offers new opportunities both in the administrative and cognitive sense. Core contribution of the doctoral thesis is an e-documentation model based on the system approach. It computerizes the nursing process from the viewpoint of holistic approach to a patient and process transparency for quality assurance. The model further incorporates interactive use of the evaluation of patient's health status thus assisting the nurse in decision making process and diminishing the probability of errors. The model was implemented as a prototype, tested in practice and critically evaluated. The thesis begins with a presentation of nursing care system, with a special emphasis on the process method of work throughout all of its phases. It is followed by a chapter on contemporary methods of documenting. Discussed is the development of documentation, patient's record and systems of classification in nursing care. The chapter ends with an overview of different existing software solutions around the world. A survey based analysis of the existing nursing documentation at all health care levels in Slovenia is described in details in the subsequent chapter. The proposed e-documentation model follows next. First it is presented as a data model and later also as a software solution. The emphasis is on the functionality stretching from data acquisition, comprehensive data processing, model use and presentation of results with respect to value added brought about to the process of documenting and implementing of nursing care. A separate chapter is dedicated to testing of the solution in practice. Testing results are summarized in the form of the SWOT analysis. Present research work is also opening up numerous new possibilities for further research, such as for example use of expert knowledge for facilitating decision making, risk evaluation, reducing the number of adverse events and possibilities for a more active involvement of the patient in the treatment process.
Keywords:Organizing, Nursing Care, E-documentation, System Approach, Nursing Process


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