Determination of maximum data set for a unified form for admission in nursing in Slovenia

Uvod: Medicinske sestre se soočajo s poplavo informacij, ki jih pridobi od pacientov. Za izdelavo holističnega plana za pacientov mora uporabiti proces zdravstvene nege. Le-tega lahko razdelimo na šest faz, to so: ocenjevanje, definiranje negovalnih diagnoz, definiranje negovalnih ciljev, iz tega načrtujemo negovalne intervencije, ko te izvedemo, je na vrsti vrednotenje. V sklopu magistrskega dela smo se osredotočili na prvo fazo procesa zdravstvene nege, in sicer na ocenjevanje, kar imenujemo tudi sprejemna anamneza zdravstvene nege. Namen: Namen magistrskega dela je ugotoviti trenutno stanje sprejemnih anamnez zdravstvene nege v Sloveniji in pripraviti model sprejemne anamneze zdravstvene nege z maksimalnim naborom podatkov. Predlagani model bo osnova za digitalizac ijo negovalne dokumentacije ob sprejemu pacienta na obravnavo v zdravstveno institucijo. Metode dela: Uporabili smo metodološki pristop načrtovanja in razvoja z razvojem artefakta. Naš artefakt je teoretični model z maksimalnim naborom podatkov za potrebe sprejemne anamneze zdravstvene nege. Model je nastal na podlagi predhodno zbranih dokumentov nekaterih slovenskih bolnišnic. Rezultati: Ugotovili smo, da večina ustanov uporablja papirnate dokumente za izpolnjevanje sprejemne anamneze zdravstvene nege. Prav tako imajo vse bolnišnice na svojih listih naštetih vsaj nekaj vnaprej pripravljenih odgovorov in veliko prostega besedila, ki ima malo prostora. Po pregledu dokumentov smo izdelali svoj teoretični model in ga razdelili po sklopih. Model, ki smo ga pripravili, je namenjen pripravi na informatizacijo sprejemne anamneze zdravstvene nege, zato smo vanj vključili tudi možnosti, ki jih papirnata dokumentacija ne more izpolniti (npr. definiranje vprašanj, ki jih lahko izpolni pacient, preskakovanje ali samodejna izpolnitev vprašanja glede na predhodne zaloge vrednosti). Razprava in zaključek: Kot je pomemben proces zdravstvene nege za obravnavo pacienta, je prav tako pomembna informatizacija tega procesa, saj prave informacijske rešitve pomagajo pri obdelavi velike količine podatkov. Za implementacijo procesa v informacijsko-komunikacijsko tehnologijo mora stroka poskrbeti za ustrezno standardizacijo jezika v zdravstveni negi. Vse to bo privedlo, da bodo medicinske sestre v klinični praksi uporabljale programske rešitve, ki bodo pomagale medicinski sestri in ne bodo same sebi namen.Introduction: Patients provide nurses with a flood of information. In order to prepare a holistic care plan for patients, nurses must follow the nursing process, which comprises six phases: assessment, establishing a nursing diagnosis, setting nursing goals, planning nursing interventions, and evaluation. In this master\u27s thesis, we focused on the first phase of the nursing process, assessment, which is also referred to as filling in a form for admission in nursing. Aim: The aim of the master\u27s thesis is to determine the current state of forms for admission in nursing in Slovenia and prepare a form for admission model, using a maximum data set. The suggested model will provide basis for the digitalisation of nursing documentation used upon a patient\u27s admission to treatment in a healthcare institution. Work methods: We adopted the methodological approach of planning and developing a tool. Our tool is a theoretical model based on a maximum data set and designed to be used when filling in forms for admission in nursing. The model was developed on the basis of documents previously collected from several Slovenian hospitals. Results: We determined that forms for admission in nursing of most of the institutions are paper documents. The documents of all hospitals also include some pre-prepared answers and many free text fields, which are rather small. Having reviewed the documents, we developed our own theoretical model and divided it into sections. The model will serve as a tool for the preparation for informatization of forms for admission in nursingtherefore, it will also include functions which cannot be used in paper documentation (defining questions to be answered by the patient, skipping questions, providing automatic answers to questions based on previous value domains, etc.). Discussion and conclusion: The nursing process is very important for patient treatment, as is the informatization of this process, since adequate information solutions help process great quantities of data. The process must be implemented in the information and communication technology in order to ensure proper standardization of language in nursing. As a result, nurses will use software solutions in clinical practice which will actually help them and will not be an end in itself