Health care documentation management in hospital conditions / Amer Ovčina, Selveta Mušanović, Ernela Eminović, Nada Spasojević, Amela Hajdarević, Jasmina Marušić.
Sažetak

Healthcare documentation or nursing documentation as often used in practice is the name of an indispensable part of a patient’s medical documentation, and documentation is an integral part of a nurse’s daily work. Documenting health care in the hospital means recording data on all procedures performed, during the entire health care process for the individual, all for the purpose of systematic monitoring, planning and evaluation of the quality of health care. Nursing documentation serves as a means of communication between the team and is of great importance for the quality and continuity of health care. AIMS: 1 - To determine the existence of health care documentation in hospital health care institutions; 2 - Examine the importance and purpose of documenting health care among nurses-medical technicians; 3 - Examine the practice of nurses-medical technicians in the process of administering health care; 4 - Present quality indicators that are monitored and analyzed through health care documentation; 5 - Compare the obtained results in two examined areas. METHODS: This research was conducted in two geographically separate areas of Sarajevo and Travnik. The study involved 210 respondents, 147 nurses-technicians employed at the Clinical Center of the University of Sarajevo and 63 nurses-technicians employed at the General Hospital in Travnik. Data collection for research was carried out by exploratory and descriptive method. An original authorized questionnaire was used for the descriptive research. The questionnaire was made available to respondents in the electronic form trough Google Forms. The anonymity of the respondents was fully guaranteed. The survey was conducted in the period from July 15- August 15, 2019. RESULTS: At the Clinical Center of the University of Sarajevo (CCU), 98% of respondents use health care documentation forms on a daily basis, and at the General Hospital Travnik 77.8% of respondents.; Dokumentacija zdravstvene njege ili sestrinska dokumentacija, kako se često naziva u praksi, neizostavan je dio medicinske dokumentacije pacijenta, a dokumentiranje je sastavni dio svakodnevnoga sestrinskog posla. Dokumentiranje zdravstvene njege u bolnici podrazumijeva zapisivanje podataka o svim provedenim postupcima tijekom cjelokupnog procesa zdravstvene njege za pojedinca, a sve u svrhu sustavnog praćenja stanja te planiranja i vrednovanja kvaliteta zdravstvene njege. Sestrinska dokumentacija služi kao sredstvo komunikacije između tima i od velike je važnosti za kvalitetu i kontinuitet zdravstvene njege. CILJEVI RADA: 1. Utvrditi postojanje dokumentacije zdravstvene njege u bolničkim zdravstvenim ustanovama. 2. Ispitati praksu medicinskih sestara/tehničara u procesu administriranja zdravstvene njege. 3. Prikazati indikatore kvalitete koji se prate i analiziraju putem dokumentacije zdravstvene njege. 4. Komparirati dobivene rezultate u dva ispitivana područja. METODE RADA: Ovo istraživanje provedeno je na dva geografski odvojena područja, u Sarajevu i Travniku. U istraživanju je sudjelovalo 210 ispitanika, i to 147 medicinskih sestara/tehničara zaposlenih u Kliničkom centru Univerziteta u Sarajevu i 63 medicinske sestre / medicinska tehničara zaposlena u Općoj bolnici u Travniku. Prikupljanje podataka za istraživanje provedeno je deskriptivnom metodom. Za deskriptivno istraživanje primijenjen je originalni autorski upitnik. Upitnik je ispitanicima bio dostupan u elektroničkom obliku u internetskoj aplikaciji Google Forms. Anonimnost ispitanika bila je u potpunosti zajamčena. Istraživanje je provedeno u periodu od 15. srpnja do 15. kolovoza 2019. REZULTATI ISTRAŽIVANJA:U Kliničkom centru Univerziteta u Sarajevu 98 % ispitanika svakodnevno upotrebljava obrasce dokumentacije zdravstvene njege, a u Općoj bolnici Travnik 77,8 % ispitanika.