Author/Editor		Krel, Cvetka; Tomažič, Jožica; Rajkovič, Vladislav; Habjanič, Ana; Benedik, Peter
Title		Oblikovanje modela elektronskega zapisa zdravstvene nege
Translated title		Building a model of electronic nursing care records
Type		članek
Source		In: Moč za spremembe - medicinske sestre in babice smo v prvih vrstah zdravstvenega sistema : zbornik prispevkov z recenzijo Ljubljana : Zbornica zdravstvene in babiške nege Slovenije - Zveza strokovnih društev medicinskih sester, babic in zdravstvenih tehnikov Slovenije, Nacionalni center za strokovni, karierni in osebnostni razvoj medicinskih sester in babic
Publication year		2013
Volume		str. 275-281
Language		slv
Abstract		Izhodišča: Pacient predstavlja središče obravnave medicinskih sester. Zdravstvena nega (ZN) pri pacientu mora biti strokovno izvedena ter ustrezno dokumentirana, da zagotovimo varnost pacientom in varstvo pacientovih podatkov. Ustrezno dokumentiranje zagotavlja zaščito dela izvajalcev zdravstvenih storitev. Temelj elektronskega zapisa ZN je enotna terminologija, standardi ZN, dosegljiva informacijska tehnologija in obstoječa zakonodaja. Zaradi pomanjkljivosti na omenjenih področjih v Sloveniji še vedno nimamo elektronskega zapisa ZN. Namen prispevka je analizirati dokumentiranje ZN v papirni in elektronski obliki. Analiziran bo oblikovan model elektronskega zapisa ZN in podane ugotovitve po testiranju v kliničnem okolju. Ustrezno oblikovan model elektronskega zapisa bi v praksi omogočal ustrezno zbiranje in obdelavo podatkov ZN in obravnavo pacienta po procesni metodi dela. Metode: Raziskava temelji na analizi obstoječe dokumentacije ZN v papirni obliki in oblikovanega modela elektronskega zapisa ZN. Testiranje modela elektronskega zapisa ZN smo izvajali maja 2012. Raziskava je vključevala 20 pacientov z Oddelka za nefrologijo v Univerzitetnem kliničnem centru Maribor. Prototipna rešitev informacijskega sistema je bila nameščena na dva stacionarna računalnika (v delovnem prostoru) in na tablični računalnik. Šest diplomiranih medicinskih sester je vnašalo podatke neposredno pri pacientu ali pa kasneje v delovnem prostoru. Primerjale so prednosti in slabosti obeh načinov zbiranja in vnašanja podatkov. Rezultati: Prototipna rešitev modela elektronskega zapisa ZN zagotavlja obravnavo pacienta po vseh fazah procesa ZN, vključuje tudi dokumentiranje venskih dostopov, punkcij in vitalnih znakov na eni vstopni točki - na zaslonskem oknu mobilne naprave, kar omogoča hiter dostop do informacij, kar pa je v papirni dokumentaciji razdrobljeno na različnih obrazcih (spremljanje intravenoznih kanalov, profil krvnega tlaka, temperaturni list...). Z analizo izdelanega modela elektronskega zapisa ZN in obstoječe dokumentacije v papirni obliki smo ugotovili, da so medicinske sestre v elektronskem zapisu bolj celostno dokumentirajo zdravstveno nego. Rezultati testiranja so povzeti v obliki zapaženih prednosti, pomanjkljivosti, priložnosti in nevarnosti, tj. v obliki analize SWOT (ang. Strengths, Weaknesses, Opportunities, Threats). Diskusija in zaključki: Raziskava pripomore k lastni oceni obstoječega dokumentiranja ZN in oceni oblikovanega modela elektronskega zapisa ZN ter oceni testiranja v klinični praksi. Vsekakor je namen elektronskega zapisa ZN strokovno ustrezno dokumentiranje ZN, ki zagotavlja varnost pacientom, varstvo pacientovih podatkov in zaščito opravljenega dela izvajalcev zdravstvenih storitev. Z dokumentiranjem in finančnim ovrednotenjem vseh posegov in postopkov ZN bi tako lahko tudi prikazali finančni delež opravljenega dela izvajalcev negovalnega tima v obravnavi pacienta.Background: The patient represents the central subject of treatment performed by a nurse. Nursing care of a patient must be performed professionally and suitably documented to ensure patient security and safety of patients data. Suitable documentation ensures protection of work performed by the health care service providers. The basis of a nursing care electronic record lies in a unified terminology, standards of nursing care, accessible information technology and existing legislation. Due to deficiencies in aforementioned areas we still do not have the nursing care electronic record established in Slovenia. The purpose of the article is to analyze the documentation of nursing care in paper and electronic form. The model of nursing care electronic record will be analyzed, and later on the results of testing in clinical environment will be presented. Suitably shaped model of electronic record could in practice enable suitable collection and processing of nursing care data, as well as patients treatment according to a process method of work. Methods: The research is based on the analysis of the existing documentation of nursing care in paper form and the proportioned model of a nursing care electronic record. Testing of the electronic nursing care record model was performed in May 2012. Twenty patients in the Department of Nephrology at University Medical Centre Maribor were involved in the research. The prototype solution of the information system was installed on two stationary computers (in the work area) and on a tablet computer. Six nurses were entering the data on the spot or later in their work space. They have compared advantages and disadvantages of both types of data collection and entering of data. Results: The prototype solution of the electronic nursing care record ensures treatment of a patient according to all process phases of nursing care, it includes documentation of venous access, punctures and vital signs at a single access point in a window of a program on mobile device, which enables quick access to information, that can be in paper documentation found on different paper forms (monitoring of intravenous drips, blood pressure profile, temperature sheet,...). With the analysis of the proportioned model of electronic nursing care record and existing documentation in paper form, we came to a conclusion, that nurses document the nursing care more comprehensively. The results of testing are given in the form of observed strengths, weaknesses, opportunities and threats, i.e. in the form of SWOT analysis. Discussion and Conclusions: The research contributes to self-evaluation of the existing nursing care documentation, and helps at evaluation of both the proportioned model of electronic record of nursing care and its testing in clinical practice. The aim of the nursing care electronic record is a professional and suitable documentation of nursing care that ensures patient security and safety of patients data and protection of work done by the health care service providers. By documentation and financial evaluation of all the procedures in nursing care, we could present the financial share of the work done by the members of nursing care team involved in patients treatment.
Keywords		zdravstvena nega dokumentiranje elektronski zapis informatika