Валеология: Здоровье, Болезнь, Выздоровление. 2020; : 282-286
СЕСТРИНСКАЯ ДОКУМЕНТАЦИЯ В ОРГАНИЗАЦИЯХ ПРАКТИЧЕСКОГО ЗДРАВООХРАНЕНИЯ
Аннотация
Ведение медицинской документации – одна из важных составляющих сестринского медицинского технологического процесса. Научить или приучить качественно оформлять документацию сестринский персонал – одна из актуальнейших проблем. Всегда во время контроля найдутся дефекты ведения документации: сокращения в записях, неразборчивый почерк, несоответствие граф или строк, замазки, подчистки и т. д. Поэтому задача руководителей среднего персонала – долгосрочное обучение в области управления документами, записями. Обучение должно охватывать весь сестринский персонал, в том числе и временных работников.
Список литературы
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6. College of Registered Nurses of Nova Scotia. Documentation guidelines for registered nurses. 2012; http://www.crnns.ca.
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11. Jasemi M., et al. Knowledge and practice of Tabriz teaching hospitals’nurses regarding nursing documentation. Thrita. 2012; 2 (2): 133–8.
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13. Taiye B. H. Knowledge and practice of documentation among nurses in Ahmadu Bello University Teaching Hospital. IOSR J Nurs Health Sci (IOSRJNHS). 2015; 4 (6): 1–6.
14. Hagos Tasew, Teklewoini Mariye and Girmay Teklay. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia // BMC Research Notes (2019) 12: 612, p. 2-6.
15. Garcia T. R., Nóbrega M. M. L. [Nursing Process: from theory to the practice of care and research]. Esc Anna Nery Rev Enferm [Internet]. 2009 Jan-Mar [cited 2014 Jul 03];13 (1): 188-93.
16. Guedes E. S., Turrini R. N. T., Sousa R. M. C., Baltar V. T., Cruz D. A. L. Attitudes of nursing staff related to the nursing process.Rev Esc Enferm USP [Internet]. 2012 Oct [cited 2014 Jul 03]; 46 (SpeNo): 130-7.
17. Antônio Fernandes Costa LimaI, Dóris Ribeiro OrtizII. Direct cost of development and documentation of the nursing process // Rev Bras Enferm. 2015; 68 (3): 596-602.
18. Cruz D. A. L. M., Guedes E. S., Santos M. A., Sousa R. M. C., Turrini R. N. T., Maia M. M., Araújo S. A. N. Nursing process documentation: rationale and methods of analytical study. Rev Bras Enferm [Internet]. 2016; 69 (1): 183-9.
Valeology: Health - Illnes - recovery. 2020; : 282-286
NURSING DOCUMENTATION IN THE ORGANIZATIONS OF PRACTICAL HEALTH CARE
Abstract
Maintaining medical records is one of the most important components of the nursing medical technological process. One of the most urgent problems is to teach or train nursing staff to prepare high - quality documentation. There are always defects in documentation management during the control process: abbreviations in entries, illegible handwriting, mismatch of graphs or lines, putty, erasures, etc. Therefore, the task of middle managers is long-term training in the field of document and record management. Training should cover all nursing staff, including temporary workers.
References
1. Elske Ammenwerth, Ulrich Mansmann, Carola Iller, Ronald Eichstädter. Factors Affecting and Affected by User Acceptance of Computer-based Nursing Documentation: Results of a Two-year Study// J Am Med Inform Assoc. 2003;10: 69–84.
2. Postanovlenie Pravitel'stva Respubliki Kazakhstan ot 1 iyulya 2014 goda № 752 «Ob utverzhdenii Plana meropriyatii po realizatsii Kontseptsii po vkhozhdeniyu Kazakhstana v chislo 30-ti samykh razvitykh gosudarstv mira na 2014-2020 gody».
3. Ostrovskaya I. V. Meditsinskie sestry i innovatsionnye tekhnologii v zdravookhranenii / I. V. Ostrovskaya // Med. sestra. — 2009. — № 3. — S. 4–9.
4. Urquhart C., Currell R., Grant M. J., Hardiker N. R. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Data Base Syst Rev. 2009; 1: 1–66.
5. Daskein R., Moyle W., Creedy D. Aged-care nurses’ knowledge of nursing documentation: an Australian perspective. J Clin Nurs. 2009; 18: 2087–95.
6. College of Registered Nurses of Nova Scotia. Documentation guidelines for registered nurses. 2012; http://www.crnns.ca.
7. Lindo J., et al. An audit of nursing documentation at three public hospitals in Jamaica. J Nurs Scholarsh. 2016; 48 (5): 499–507.
8. Collins S. A., et al. Relationship between nursing documentation and patients’ mortality. Am J Crit Care. 2013; 22 (4): 306–13.
9. Lindo J., et al. An audit of nursing documentation at three public hospitals in Jamaica. J Nurs Scholarsh. 2016; 48 (5): 499–507.
10. Broderick M. C., Coffey A. Person centred care in nursing documentation. Int J Older People Nurs. 2013; 8 (4): 309–18.
11. Jasemi M., et al. Knowledge and practice of Tabriz teaching hospitals’nurses regarding nursing documentation. Thrita. 2012; 2 (2): 133–8.
12. Sum M. T., Chebor M. A. Documentation: historical perspectives, purposes,benefits and challenges as faced by nurses. Int J Hum Soc Sci. 2013; 3 (16): 236–40.
13. Taiye B. H. Knowledge and practice of documentation among nurses in Ahmadu Bello University Teaching Hospital. IOSR J Nurs Health Sci (IOSRJNHS). 2015; 4 (6): 1–6.
14. Hagos Tasew, Teklewoini Mariye and Girmay Teklay. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia // BMC Research Notes (2019) 12: 612, p. 2-6.
15. Garcia T. R., Nóbrega M. M. L. [Nursing Process: from theory to the practice of care and research]. Esc Anna Nery Rev Enferm [Internet]. 2009 Jan-Mar [cited 2014 Jul 03];13 (1): 188-93.
16. Guedes E. S., Turrini R. N. T., Sousa R. M. C., Baltar V. T., Cruz D. A. L. Attitudes of nursing staff related to the nursing process.Rev Esc Enferm USP [Internet]. 2012 Oct [cited 2014 Jul 03]; 46 (SpeNo): 130-7.
17. Antônio Fernandes Costa LimaI, Dóris Ribeiro OrtizII. Direct cost of development and documentation of the nursing process // Rev Bras Enferm. 2015; 68 (3): 596-602.
18. Cruz D. A. L. M., Guedes E. S., Santos M. A., Sousa R. M. C., Turrini R. N. T., Maia M. M., Araújo S. A. N. Nursing process documentation: rationale and methods of analytical study. Rev Bras Enferm [Internet]. 2016; 69 (1): 183-9.
