20.500.12556/ReVIS-10930 NAČELA DOBREGA DOKUMENTIRANJA V ZDRAVSTVENI NEGI PRINCIPLES OF GOOD DOCUMENTATION IN HEALTHCARE Teoretična izhodišča: Dokumentiranje v zdravstveni negi predstavlja pomemben element sodobne zdravstvene nege. Zajema zapisovanje vseh aktivnosti zdravstvene nege, vključno z avtonomnimi, soodvisnimi in odvisnimi aktivnostmi. Dokumentiraje v zdravstveni negi lahko opredelimo kot zbiranje in zapisovanje vseh podatkov, ki jih medicinska sestra pridobi od pacienta. Pomembno je za zagotavljanje kontinuirane, varne in kakovostne obravnave in oskrbe pacienta. Z ustreznim dokumentiranjem preprečujemo neželene dogodke, omogočamo prenos in ohranjanje informacij, uspešno komunikacijo med pacientom in zdravstvenim delavcem, analizo in vrednotenje lastnega dela, zmanjšujemo možnost nastanka napak in dajemo možnost za izvajanje znanstveno raziskovalnega dela. Ustrezna negovalna dokumentacija ima različna načela, vključno z objektivnostjo, specifičnostjo, jasnostjo in doslednostjo, celovitostjo, spoštovanjem zaupnosti in beleženjem napak Metode: Raziskava je temeljila na kvantitativni raziskovalni metodi preučevanja in deskriptivni metodi dela. Za potrebe empiričnega dela smo analizirali primarne vire, ki smo jih pridobili z metodo anketnega vprašalnika, za teoretični del pa smo uporabili sekundarne podatke, ki smo jih pridobili s pregledom domače in tuje strokovne ter znanstvene literature, pridobljene iz knjižnice in prostodostopnih podatkovnih baz (PubMed, Cobiss). Rezultati: V raziskavi so sodelovali zaposleni v zdravstveni negi. Raziskava je potekala na primarni, sekundarni in terciarni ravni zdravstvene dejavnosti. Vključenih je bilo 105 anketirancev, od tega 75 (71,4 %) žensk in 30 (28,6 %) moških. Največ anketirancev (34; 32,4 %) je bilo iz starostne skupine 41 let in več, najmanj (14; 13,3 %) pa jih je bilo starih od 20 do 25 let. Večina anketirancev (36; 34,3 %) ima srednješolsko izobrazbo. 30 (28,6 %) zaposlenih dela v zdravstvenem domu, 29 (27,6 %) v bolnišnici, 20 (19,0 %) v domu starejših občanov, 9 (8,6 %) pa je zaposlenih v drugih ustanovah. Razprava: Anketirani zdravstveni delavci se zavedajo pomena dokumentiranja zdravstvene nege. Njihovo mnenje je, da dobra dokumentacija nudi kakovostno in varno oskrbo pacienta. Na podlagi raziskave lahko rečemo, da so zaposleni v zdravstveni negi dobro seznanjeni z načeli dobrega dokumentiranja v zdravstveni negi. Ključne besede: Medicinska sestra, načela, dokumentiranje v zdravstveni negi, dokumentacija. Introduction: Documentation in nursing care is a crucial element of modern healthcare. It includes recording all nursing activities, including autonomous, interdependent, and dependent activities. Documentation in nursing can be defined as the collection and recording of all data obtained by the nurse from the patient. It is essential for ensuring continuous, safe, and high-quality patient care. Proper documentation prevents adverse events, facilitates the transfer and preservation of information, supports effective communication between the patient and healthcare provider, enables analysis and evaluation of one’s work, reduces the likelihood of errors, and provides opportunities for scientific research. Proper nursing documentation adheres to principles including objectivity, specificity, clarity, consistency, comprehensiveness, confidentiality, and error recording. Methods: The research was based on quantitative research methodology and descriptive work methods. For the empirical part, primary sources were analysed through surveys, while secondary data were collected from domestic and international professional and scientific literature, available in libraries and free-access databases (PubMed, COBISS). Results: The study included nursing staff employed at primary, secondary, and tertiary levels of healthcare. A total of 105 respondents participated, with 75 (71.4%) women and 30 (28.6%) men. The majority of respondents (34; 32.4%) were aged 41 and above, while the smallest group (14; 13.3%) were aged 20-25 years. Most respondents (36; 34.3%) had completed secondary education. Of the participants, 30 (28.6%) worked in health centres, 29 (27.6%) in hospitals, 20 (19.0%) in nursing homes, and 9 (8.6%) in other institutions. Discussion: The surveyed healthcare professionals recognize the importance of documenting nursing care. They believe that good documentation provides quality and safe patient care. Based on the research, we can say that nursing staff are well acquainted with the principles of good documentation in nursing. Keywords: Nurse, principles, nursing documentation, documentation. Medicinska sestra načela dokumentiranje v zdravstveni negi dokumentacija. Nurse principles nursing documentation documentation. true false false Slovenski jezik Angleški jezik Diplomsko delo/naloga 2024-10-30 10:25:20 2024-10-30 10:25:20 2024-12-10 03:03:30 0000-00-00 00:00:00 2024 0 0 0000-00-00 NiDoloceno NiDoloceno NiDoloceno 0000-00-00 0000-00-00 0000-00-00 21078 218212355 DIP_Luzar_Lara_2024.pdf DIP_Luzar_Lara_2024.pdf 1 46CE2B27FAA217BFCEE9E9851226839C c7c7fab79ff59062273304697c2c97404b3e03a016f0d602e2be149515c57112 e2182201-96a0-11ef-89f3-001a4af901a5 https://revis.openscience.si/Dokument.php?lang=slv&id=12484 Univerza v Novem mestu - Fakulteta za zdravstvene vede 0 0 0