Avtor/Urednik		Ramšak-Pajk, Jožica
Naslov		Dokumentacija v zdravstveni negi: pregled literature
Prevedeni naslov		Documentation in nursing care: literature review
Tip		članek
Vir		Obz Zdrav Nege
Vol. in št.		Letnik 40, št. 3
Leto izdaje		2006
Obseg		str. 137-42
Jezik		slo
Abstrakt		Documentation in nursing care in an important part of the whole documentation of a patient. Documentation of nursing care presents the documentation of separate phases of the process of nursing care. Documentation of nursing care has an important impact on the continuation and quality of nursing care, on communication among health team members and can also represent a basis for research work. In order to present a survey of literature, descriptive research method was used. Sources, contents and results of the research were processed to show the above stated facts about the purpose of the documentation of nursing care and in the light of some factors influencing it: information technology, points of view of nurses, ethics of their work and teaching process. The survey of literature revealed that several research studies and documents exist and that nursing care documentation takes on many forms, form written ones to computer assisted. Different classification systems are used. The majority of the mentioned studies have supported the above mentioned presumptions and that nursing care documentation has many positive aspects.
Izvleček		Dokumentacija zdravstvene nege je pomemben del celotne zdravstvene dokumentacije pacienta. Predstavlja dokumentacijo posameznih faz procesa zdravstvene nege. Vpliva na zagotavljanje kontinuirane in kvalitetne zdravstvene nege, kornunikacijo med člani zdravstvenega tima ter je lahko osnova raziskovanju. Za namen pregleda literature in prikaza virov je bila uporabljena opisna raziskovalna metoda. Viri, vsebine in rezultati raziskav so obdelani glede na potrditev najpogosteje navedenih dejstev o namenu dokumentacije zdravstvene nege in glede na nekatere dejavnike dokumentacije zdravstvene nege: informacijska tehnologija, stališča medicinskih sester, etični vidik in izobraževanje. Pregled literature je pokazal, da je množica tovrstnih raziskav in zapisov. Poskusov uvajanja dokumentacije zdravstvene nege, tako pisne kot računalniško podprte, je veliko. Pri tem so pogosto uporabljeni nekateri klasifikacijski sistemi. Večina raziskav potrjuje zgoraj navedena dejstva in prednosti uporabe dokumentacije zdravstvene nege.
Deskriptorji		NURSING RECORDS ETHICS, NURSING