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Nursing Diagnosis & Midwifery 2018
S e p t e m b e r 1 0 - 1 1 , 2 0 1 8
P r a g u e , C z e c h R e p u b l i c
Page 32
Journal of Nursing and Health Studies
ISSN: 2574-2825
E u r o S c i C o n E v e n t o n
Nursing Diagnosis &
Midwifery
Statement of the Problem:
The quality nursing documentation, which follows
the steps of the nursing process, ensures systematic nursing care of patients
and provides support to nurses in clinical decision-making. The literature
review, however, shows that data gaps and inaccurate data are often listed
in the documentation and that documentation is often lacking in important
information. The electronic records and standardized nursing language
influence the improvement of the quality of nursing documentation, yet the
area is still not well researched. The purpose of this pilot study is to validate
the Slovenian version of Quality of Diagnoses, Interventions, and Outcomes
(Q-DIO) Instrument and to compare the quality of paper-based records versus
electronic records.
Methodology:
A cross-sectional observational study will be carried out using
a standard Q-DIO instrument. The sample for the pilot study will include 30
health records (10 electronic and 20 paper-based records) of children aged 1
to 9 years diagnosed with lower respiratory infection. Children included in the
study were hospitalized in 2017 in three different tertiary clinics in Slovenia.
Findings & Conclusion:
We expect that the quality of electronic records will be
significantly higher in comparison with paper-based records.
Biography
Maja Klancnik Gruden is an Assistant chief nursing officer for
quality and development in University Medical Centre Ljubljana
and a Teaching assistant at the University of Maribor, Faculty
of Health Sciences. She is one of the founding members
of the Working group for nursing diagnosis who led the
translation project of the book NANDA–International Nursing
Diagnoses: Definitions and Classification 2015–2017. She is
a PhD candidate in Nursing. Her field of research is focused
on nursing documentation, especially the development and
implementation of electronic health records related to the
theory of person-centred nursing.
maja.klancnik@kclj.siAndreja Mihelic Zajec is a lecturer of basic nursing, research
methodology in nursing and nursing care of women at the
Department of Nursing, University of Ljubljana, Faculty of
Health Sciences. She was the editor-in-chief of the only
scientific journal in the field of nursing in Slovenia. She is one
of the founding members of the Working group for nursing
diagnosis which led the translation project of the book NANDA–
International Nursing Diagnoses: Definitions and Classification
2015–2017.
andreja.mihelic@zf.uni-lj.siThe comparison of the quality of nursing documentation
between written and electronic health records: a pilot study
Maja Klancnik Gruden
1
and Andreja Mihelic Zajec
2
1
University Medical Centre Ljubljana, University of Maribor, Slovenia
2
University of Ljubljana, Slovenia
Maja Klancnik Gruden et al., J Nurs Health Stud 2018 Volume: 3
DOI: 10.21767/2574-2825-C4-011