Journal of Nursing and Health Studies

The comparison of the quality of nursing documentation between written and electronic health records: a pilot study

EuroSciCon Event on Nursing Diagnosis & Midwifery
September 10-11,2018 Prague,Czech Republic

Maja Klancnik Gruden and Andreja Mihelic Zajec

University Medical Centre Ljubljana, University of Maribor, Slovenia University of Ljubljana, Slovenia

ScientificTracks Abstracts: J Nurs Health Stud

DOI: 10.21767/2574-2825-C4-011

Abstract

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. 

Andreja 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.

E-mail: maja.klancnik@kclj.si   

andreja.mihelic@zf.uni-lj.si