Author/Editor		Šušteršič, Olga; Rajkovič, Vladislav; Kljajić, Miroljub
Title		Nova kakovost, ki jo prinaša strukturiran zapis v dokumentiranju zdravstvene nege
Translated title		New quality as the result of a structured record in nursing care documentation
Type		članek
Source		Obz Zdrav Nege
Vol. and No.		Letnik 34, št. 5-6
Publication year		2000
Volume		str. 185-92
Language		slo
Abstract		Documentation is an important element of modern nursing care, assuring continuity, reflecting professionalism and offers a basis for evaluation of nursing care. Successful documentation is an essential part of the process method of work, including evaluation of a clients or patients health status. It represents the basis for the definition of nursing problems, diagnoses and planning of nursing care. The change and progress in health status is an indicator of a successful nursing process. The evaluation of nursing interventions is as a rule reflected in positive changes in separate life activities. Therefore, follow-up of changes in health status of a client or patient should be carried out in regular intervals and on the basis of indicators in the frames of separate life activities. For the assessment of the clients status theory of multicriteria decision making and shell of expert system DEX is used, enabling the presentation of decision making knowledge with criteria structure and evaluation explanation. Nursing care is thus rounded into a unified system enabling holistic treatment of subjects on the basis of transparent information support, selective discussion of critical factors and analysis of results in the frames of what-if. Into the hierarchical structure of indicators of the holistic evaluation and fourteen life activities of a patient or client measurement scales of five descriptive values and aggregation functions are introduced. The process method of work is thus complemented with additional practically applicable cybernetic solution with feed back evaluation which is an important element of the treatment of nursing phenomena in the presentation of knowledge in health field.
Summary		Dokumentiranje je pomemben element sodobne zdravstvene nege. Zagotavlja kontinuiteto, odraža profesionalnost in daje osnovo za vrednotenje zdravstvene nege. Uspešna dokumentacija je bistvena sestavina procesne metode dela, ki vključuje ocenjevanje varovančevega oziroma bolnikovega zdravstvenega stanja. To je osnova za opredelitev negovalnih problemov oziroma diagnoz in načrtovanja zdravstvene nege. Sprememba oziroma izboljšanje zdravstvenega stanja je indikator uspešnosti izvajanja zdravstvene nege. Ocena ustreznosti negovalnih intervencij se praviloma odraža v pozitivnih spremembah pri posameznih življenskih aktivnostih. Zato je potrebno spremljanje sprememb zdravstvenega stanja varovanca oziroma bolnika v določenih časovnih intervalih na osnovi indikatorjev v okviru posameznih življenskih aktivnosti. Za ocenjevanje stanja varovanca oziroma bolnika je uporabljena teorija večkriterijskega odločanja in lupina ekspertnega sistema DEX, ki omogoča predstavitev odločitvenega znanja s strukturo kriterijev ter razlago ocen. Zdravstvena nega je tako zaokrožena v enovit sistem, ki omogoča celostno obravnavo subjektov na osnovi transparentne informacijske podpore, selektivno obravnavo kritičnih dejavnikov in analiz rezultatov v pogledu "kaj-če". V hierarhično strukturo indikatorjev celostne ocene in štirinajstih življenskih aktivnosti varovanca oziroma bolnika, so uvedene merske lestvice petih opisnih vrednosti in agregacijske funkcije. Tako je v procesno metodo dela zdravstvene nege vnesena dodatna praktično izvedljiva kibernetična rešitev s povratno evalvacijsko zanko, ki je pomemben element obravnave negovalnih fenomenov v predstavitvi znanja na področju zdravstva.
Descriptors		NURSING CARE NURSING RECORDS NURSING ASSESSMENT