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Electronic versus writen form of nursing documentation - the wiews and preferences of nurses.
KOMARDINOVÁ, Petra
Abstract This bachelor thesis deals with nursing documentation in electronic and paper forms. Nursing documentation is a part of medical documentation and it is regulated by the same rules. It consists of records about nursing activities performed in respect to the patient. It also contains nursing case history, evaluation of the care of the patient, records about the patient´s condition, discharge and relocation reports and other documents, such as pain scales, Barthel index, Glasgow coma scale, records on bedsores, intake and excretion of liquids, monitoring of vital functions, Norton scale or records about wound treatment. To ensure a quality care of a patient it is very important to keep uniform nursing documentation. The bachelor thesis had four objectives. The first objective was to survey nurses´ opinions of individual types of nursing documentation. The second objective was to find out which type of nursing documentation is preferred by nurses and whether they prefer nursing documentation in paper or electronic form. The third objective was to define the form of nursing documentation used by the surveyed medical facilities. The last objective was to identify problems encountered in the course of introduction of electronic nursing documentation. To achieve those objectives I approached respondents from two medical facilities. Seven respondents answered questions in one-to-one interviews in the retirement home Máj in České Budějovice and the same number of respondents answered questions in one-to-one interviews in the Hospital České Budějovice a.s. The collection of qualitative data consisted in the individual nature of the interviews with the respondents. After the processing the data have shown that respondents from the retirement home Máj expressed their complete satisfaction with the nursing documentation in electronic form. The respondents from the Hospital in České Budějovice preferred nursing documentation on paper, however, they believed that the documentation should be modified. Some of them were interested in trying nursing documentation in electronic form. The results of the bachelor thesis have shown different opinions of the nursing documentation among the respondents. The conclusions from the research may play a key role in decision-making about the introduction of a new documentation or improvement of the already well-established nursing documentation in medical facilities.
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