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Nurse documentation in Czech republic
RAK, Michal
Topic of the diploma paper: Nursing Documentation in the Czech Republic. The paper compares nursing documentations used in various health-care establishments. Examining their printed form, it takes their main parts and focuses on the contents of individual components and on the records of implementation of the nursing process. These areas are analyzed and compared in the practical part of the paper. The objective of the diploma paper was to ascertain what documentation is used by health-care establishments in the Czech Republic and to compare these internal materials. From 49 contacted establishments in all regions of the Czech Republic, the research covered 15 establishments that consented to cooperation and provided nursing documentation in a printed form. All obtained materials were analyzed and used in research. In order to attain the objectives, qualitative research was used. A record sheet, based on 12 areas of the Gordon{\crq}s model, was made up for the purposes of the comparison. Individual documentations were kept and processed, and are referred to in the paper under letters of the alphabet so that anonymity of the research is maintained. Individual materials were analyzed. The contents of the sheets were compared and evaluated. The collected data were processed by means of Microsoft Office Word program. From the results of the research it is apparent that the documentations maintained by all the health-care establishments have a similar composition. They contain the nursing anamnesis, nursing care plan and other documents examined in detail in the paper. The nursing anamnesis is divided into individual fields that are not based on any mode and whose number varies. Measuring techniques are used in the documentations. The most widespread was Barthel{\crq}s test of activities of daily living. A nursing anamnesis is connected with a nursing care plan. All 15 documentations contain this plan. Six health-care establishments decided for a free form, six establishments for a preprinted form and the last three establishments combined the printed and the free form into one. According to the findings, all the examined samples are on a comparable level and comply with all the criteria of quality care of a patient, given by the needs of practice. The results of the paper will be provided to the cooperating establishments that may use them in order to achieve better quality of patient records.
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