Analiza toka in načina hrambe podatkov o obravnavah pacientov v Urgentnem kirurškem bloku UKC Ljubljana : magistrsko delo

Arbajter, Simon (author), Mraz, Miha (mentor), Moškon, Miha (comentor)

Uvod: V zdravstveni dejavnosti je poleg pregleda in oskrbe pacienta zelo pomembno ustrezno dokumentiranje njegove obravnave. Zdravstvena dejavnost v Sloveniji in tudi širše po svetu v večini še vedno temelji na dokumentaciji v papirni obliki. Tudi v Urgentnem kirurškem bloku Univerzitetnega kliničnega centra Ljubljana obravnava pacienta še vedno v veliki meri temelji na zdravstveni dokumentaciji v papirnati obliki. To vpliva tako na stroške kot tudi na samo kakovost obravnave. Zato je nujno potrebno nadaljevati z digitalizacijo delovanja. Namen in cilj: Namen magistrskega dela je analizirati tok in način hrambe podatkov o obravnavah pacientov. Na podlagi navedenih ugotovitev bomo izdelali diagram toka podatkov in aktivnosti, ki predstavlja osnovo za nadaljnjo digitalizacijo. Cilj dela je na podlagi opisane analize identificirati možnosti za prehod na brezpapirno delovanje oziroma podati predloge za nadaljnjo digitalizacijo poslovnega procesa. Metode dela: V magistrskem delu je uporabljena deskriptivna metoda dela. Podatki so zbrani z opazovanjem, pregledom literature in so kvantitativno ter analitično obdelani. Kot strategija dela je uporabljena študija primera. Rezultati: V pričujočem delu smo analizirali, kateri podatki in v kakšni obliki vstopajo v sistem ob pričetku obravnave pacienta v Urgentnem kirurškem bloku, kateri podatki in v kakšni obliki se tekom obravnave porajajo, ter kateri podatki in v kakšni obliki so izhodni podatki, ki so predvideni za hrambo. Analizirali smo tudi povezave med njimi. Na podlagi navedenih ugotovitev smo izdelali diagram toka podatkov in aktivnosti, ki predstavlja osnovo za nadaljnjo digitalizacijo delovanja. V nadaljevanju smo podali predloge za digitalizacijo podatkov oziroma dokumentov, ki so v papirni oziroma fizični obliki, in predloge za nadgradnjo obstoječe informacijske rešitve. Grafično smo prikazali tudi potrebe po nadgradnji IKT glede na prostorsko razporeditev. Opisali smo tudi težave, ki bi se utegnile pojaviti pri procesu nadaljnje digitalizacije. Razprava: Na podlagi analize smo ugotovili, da bi ob ustrezni nadgradnji obstoječe informacijske rešitve lahko večina podatkov oziroma dokumentov v papirni obliki brez težav digitalizirali in shranili v elektronski obliki. Popolna digitalizacija prinaša vrsto prednosti pri vsakdanjem delu, vendar je potrebno kljub temu ohraniti možnost hitrega prehoda na delovanje v papirni obliki v primeru težav z delovanjem IKT oziroma v primeru delovanja zavoda v izrednih razmerah.

• Language: Slovenian
• Keywords: Urgentni kirurški blok, zdravstvena dokumentacija, brezpapirno delovanje, tok podatkov, EZZ, elektronska baza podatkov
• Work type: Master's thesis/paper
• Organization: ZF - Faculty of Health Sciences
• Year: 2017
• PID: 20.500.12556/RUL-95307
• COBISS.SI-ID: 5323371
• Publication date in RUL: 20.09.2017

Secondary language

• Language: English
• Title: Analysis of patient data management process in the Surgical emergency unit of UMC Ljubljana : masterʹs thesis

Abstract

Introduction: Apart from medical examination and patient care, documentation of treatment is very important in the medical practice. Medical practice in Slovenia and worldwide is generally still based on paper-form documentation. Surgical emergency unit in University medical centre Ljubljana still treats patients based on paper-form documentation. This has influences on expenses as well as on the quality of treatment. Continual digitalisation in this area is hence essential. Purpose and goal: The purpose of this M.A. thesis is analysing data flow and ways of data storage of patients' treatments. Based on our findings we created a data flow and activities diagram, which represents the basis for continual digitalisation. The goal of this thesis is to identify possibilities to switch to paperless operations or to give suggestions for continual digitalisation of the business process. Methods of work: In the thesis, the descriptive method is used. The data was collected through observation, inspection of literature and has undergone quantitative and analytical processing. The work strategy follows a case study research design. Results: In the present work we have analysed which data and in what form enters the system at the beginning of patient treatment in the Surgical emergency unit, which data and in what form emerges during the patients’ treatments, and which data and in what form represents the exit data, which is also intended for storage. Based on our findings we have created a data flow and activities diagram, which represents the basis for continual digitalisation of operations. Next, we followed with suggestions for digitalisation of data or documents in paper form and suggestions for upgrading the current system. We graphically illustrate the need for ICT upgrade based on the current spatial layout and the problems which might appear during the process of digitalisation. Discussion: Based on the analysis we discovered that a suitable ICT upgrade would allow for a seamless transition to digitalised and paperless storage of data or documents. Despite all the advantages of total digitalisation in everyday practice an option to switch back to paper-form operations has to be available in the event of problems with the ICT or in the event of an emergency operations plan of the institute.

• Keywords: Surgical emergency unit, healthcare documentation, paperless operations, data flow, electronic health record, digital data base