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's 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's 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's 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 nursing; therefore, 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.
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