Creating and a Pilot Authentication of a Unified Medical Documentation. A Case study in the Regional Hospital Náchod

This thesis is based on the results of the diagnostics of an organisation that I carried out in the Regional Hospital Náchod. I work in the top management as a charge nurse. The thesis is divided into a theoretical part and a practical one. The legal regulations are dealt with in the theoretical part. They modify the administration of the medical documentation; the description of the nursing process, the files of the nursing documentation and regulations for managing the nursing documentation. The focus of this thesis lies in the research part. It is based on the diagnostics of an organisation that I carried out in the hospital. It was part of a contract made with the Faculty of Humanities at the Charles University in Prague. The contract was about the diagnostics of the medical documentation with an emphasis on the nursing documentation. The analysis of the documentation was carried out in all the departments of every regional hospital, which is a part of the Náchod Regional Hospital, i. e. the regional hospitals in Náchod, Broumov, and Opočno. I found out that the nursing documentation is not unified in the hospitals. Each department was using different types of documentation including their content. The documentation was not standardised. During my research, I also found several mistakes in the..