Abstract
Health documentation is a prerequisite for good and sustainable health and social care. It is especially important for patient involvement and their empowerment. A transition from paper to e-documentation together with the electronic patient record should be based on thorough knowledge of the current state of documentation and its usages. The main objective of this paper was to analyse which documents and work methods of documenting processes within nursing are being used within different environments. Furthermore, what are the main reasons for their discrepancies from theoretical approaches and best practices. The analysis is based on a survey carried out on all three levels of healthcare. The survey questionnaire consisted of 12 questions to which responded 286 nursing teams from community health centres, hospitals and retirement homes in Slovenia. The results point to diversity in documenting as well as lack of interoperability. This is reflected in a great number of different documents. All phases of the nursing process were being documented in only 31.8 % of cases. The main reasons for this can be attributed to work organisation, different definitions of data-set requirements and inadequate knowledge by nurses. Survey results pointed out a need for the renewal of nursing documentation towards a more uniform system based on contemporary health technologies.
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Notes
The values of responses were transformed into numerical values with the lowest value 1 meaning the respondents disagree with the statement (answer »no«). The highest value 3 means the respondents agree with the statement (answer »yes«). Middle value 2 corresponds to the answer »to some extent«. That is how the average values were calculated.
The first value in the parenthesis is the average value of responses calculated for the tenth question and the second one is the average value of responses to the eleventh question.
25.3 % of those who provided answers to the question of the open type.
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Acknowledgments
The authors are grateful to the nurses from the Community Health Centre of Ljubljana, University Medical Centre Ljubljana, University Medical Centre Maribor and retirement homes in Ljubljana: Moste-Polje, Šiška and Tabor for their participation in the survey.
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This research was financially supported by the Ministry of Health of the Republic of Slovenia, contract number C2711–707,502.
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This article is part of the Topical Collection on Systems-Level Quality Improvement
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Rajkovič, U., Kapun, M.M., Dinevski, D. et al. The Status of Nursing Documentation in Slovenia: a Survey. J Med Syst 40, 198 (2016). https://doi.org/10.1007/s10916-016-0546-x
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DOI: https://doi.org/10.1007/s10916-016-0546-x