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Optimization of nursing documentation
KUBIČKOVÁ, Jesika
The presented thesis addresses the topic of nursing documentation and its management. The theoretical part of this thesis is focused on nursing documentation, its history and legislation. Further, it focuses specifically on its content, forms and practices necessary to follow when managing the documentation. There are three main forms of nursing documentation that are widely used nowadays. These forms include paper-based documentation, electronic documentation and photo documentation. Further, the thesis describes the responsibility for nursing documentation and possible mistakes that may appear during documentation management. Another area being addressed within the theoretical part of this thesis is the quality of nursing care, which is closely linked to the management of nursing documentation. Here, standardization of nursing care is described as well as its quality indicators, audit, and accreditation. A combination of qualitative and quantitative research was chosen to implement the survey. Qualitative research was carried out using semi-structured interviews and quantitative research was carried out using questionnaire survey and content analysis of nursing documentation. The first objective was to compare nursing documentation in chosen nursing facilities. It was proven that the majority of nurses use the combination of paper-based nursing documentation and electronic documentation. In contrast, only a small minority of surveyed nurses use electronic form of nursing documentation exclusively. The second chosen objective was to survey the perception of the current nursing documentation quality. This survey showed that the majority of nurses find the current nursing documentation to be satisfactory, however, there is still a significant number of nurses, who find the current version of the documentation to be limiting. The last objective was to collect specific requirements for nursing documentation from the surveyed nurses. These results are given further on, in the Discussion part. The result of the research is that most nurses typically find the current nursing documentation to be satisfactory. Many of them find nursing documentation to be important and beneficial, not only for their own purposes, but also for their patients and high-quality nursing care in general. Our survey opens up possibilities for a deeper research that may be focused on comparing paper-based nursing documentation with its electronic form. Given the fact that most of the industries nowadays are gradually shifting towards electronization, healthcare is not an exception. One area in specific that is worth researching further would be surveying the facilities that already embraced the electronic nursing documentation, specifically the impact of the transition on the overall quality of nursing care.
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