Primerjava dveh aplikacij za dokumentiranje v zdravstveni negi – dokumentiranje načrta zdravstvene nege : magistrsko delo

Drnovšek, Rok (author), Rajkovič, Vladislav (mentor), Milavec Kapun, Marija (comentor)

Uvod: Informatika v zdravstveni negi je pomembno specializirano področje zdravstvene nege, katerega naloga je aktivno sodelovanje pri snovanju in implementaciji aplikacij za elektronsko dokumentiranje v zdravstvu. Proces zdravstvene nege je temeljno izhodišče za načrtovanje in izvajanje zdravstvene nege in mora biti ustrezno reprezentiran v sodobnih načinih dokumentiranja zdravstvene nege. Namen: Namen magistrskega dela je primerjati uporabniško izkušnjo in kakovost dokumentiranih načrtov zdravstvene nege pri uporabi dveh različnih aplikacij za dokumentiranje v zdravstveni negi. Metode dela: V raziskavi smo primerjali aplikacijo E-dokumentacija v patronažni zdravstveni negi in aplikacijo Think!Med Clinical™. Podatke za ocenjevanje kakovosti uporabniške izkušnje smo zbirali z anketo. Dokumentirane načrte zdravstvene nege smo kvantitativno in kvalitativno analizirali. Kvalitativna analiza je temeljila na oceni z dvema preizkušenima orodjema za ocenjevanje kakovosti negovalnih načrtov. V raziskavi je sodelovalo 69 študentov zdravstvene nege. Rezultati: Študenti so aplikacijo Think!Med Clinical™ ocenili statistično značilno boljše v vseh vsebinskih sklopih vprašalnika. S kvantitativno analizo smo zaznali statistično značilne razlike pri doslednosti dokumentiranja posameznih segmentov načrta zdravstvene nege v prid aplikacije E-dokumentacija v patronažni zdravstveni negi. Pri ocenjevanju dokumentiranih načrtov zdravstvene nege z avstralskim orodjem za ocenjevanje kakovosti dokumentacije v zdravstveni negi starostnika nismo zaznali statistično značilnih razlik (p = 0,098). Pri ocenjevanju dokumentiranih načrtov zdravstvene nege z orodjem za ocenjevanje kakovosti negovalnih diagnoz in intervencij ter ciljev zdravstvene nege smo zaznali statistično značilno razliko srednjih vrednosti končnih ocen v prid aplikacije E dokumentacija v patronažni zdravstveni negi (p = 0,035). Razprava in zaključek: Aplikacija Think!Med Clinical™ je zagotovila boljšo uporabniško izkušnjo, ker je vizualno privlačna, hitra in omogoča preprosto dokumentiranje negovalnih diagnoz. Študenti so z aplikacijo E-dokumentacija v patronažni zdravstveni negi doslednejše dokumentirali ključne segmente načrta zdravstvene nege in posledično bolj kakovostno dokumentirali proces zdravstvene nege. Strukturne pomanjkljivosti načrtov zdravstvene nege v aplikaciji Think!Med Clinical™ so posledica nepopolne vključitve standardiziranih negovalnih diagnoz v zasnovo aplikacije, saj aplikacija uporabniku ne nudi dovolj etioloških dejavnikov in v svoji zasnovi ne predvideva dokumentiranja diagnostičnih kazalcev.

• Language: Slovenian
• Keywords: standardizirani jeziki, NANDA-I, elektronsko dokumentiranje, proces zdravstvene nege, medicinska sestra
• Work type: Master's thesis/paper
• Organization: ZF - Faculty of Health Sciences
• Year: 2018
• PID: 20.500.12556/RUL-102265
• COBISS.SI-ID: 5468267
• Publication date in RUL: 03.08.2018

DRNOVŠEK, Rok, 2018, Primerjava dveh aplikacij za dokumentiranje v zdravstveni negi – dokumentiranje načrta zdravstvene nege : magistrsko delo [online]. Master’s thesis. [Accessed 31 March 2025]. Retrieved from: https://repozitorij.uni-lj.si/IzpisGradiva.php?lang=eng&id=102265

Secondary language

• Language: English
• Title: Comparison of two applications for documentation in nursing – nursing care plan documentation : masterʹs thesis

Abstract

Introduction: Nursing informatics is an important nursing specialty that should actively engage in development and implementation of electronic applications for healthcare documentation. The nursing process is a foundation of systematic planning and implementation of nursing care and as such, it should be adequately represented in modern applications for electronic documentation in nursing. Purpose: The purpose of this Master’s thesis is to compare two applications for electronic documentation in nursing. The comparison is focused on the user experience and on the quality of documented nursing care plans. Methods: The study compared the applications E-documentation in community nursing (E-dokumentacija v patronažni zdravstveni negi) and Think!Med Clinical™. The user experience data was collected with a survey and the documented nursing care plans were qualitatively and quantitatively analyzed. Qualitative analysis was implemented with two previously validated instruments for quality evaluation of nursing documentation. The study sample included 69 undergraduate nursing students. Results: The Think!Med Clinical™ application was significantly better evaluated by the students in all the survey segments. However, the quantitative analysis of documented nursing care plans revealed a significant difference in consistent use of crucial nursing care plan segments in the documentation, where the E-documentation in community nursing application showed better results. The assessment of nursing care plans with the Quality of Australian Nursing Documentation in Aged Care instrument revealed no significant differences (p = 0,098), while the assessment with the Quality of Nursing Diagnoses, Interventions, and Outcomes instrument revealed a significant difference in the final score means (p = 0,035) in favor of the E-documentation in community nursing application. Discussion and conclusion: The Think!Med Clinical™ application delivered a better user experience thanks to its visual design, speed and simplicity of use for nursing diagnosis documentation. However, the students using the E-documentation in community nursing application more consistently documented crucial nursing care plan segments, which resulted in better quality of the nursing process documentation. The structural faults of nursing care plans made with the Think!Med Clinical™ application are a consequence of incomplete implementation of standardized nursing diagnoses in the application design, since the application includes an inadequate number of possible related factors and does not include defining characteristics as a structural part of the nursing diagnosis.

• Keywords: standardized languages, NANDA-I, electronic documentation, nursing care process, nurse