title: The Status of Nursing Documentation in Slovenia: a Survey.
abstract: Health documentation is a prerequisite for good and sustainable health and social care. It is especially important for patient involvement and their empowerment. A transition from paper to e-documentation together with the electronic patient record should be based on thorough knowledge of the current state of documentation and its usages. The main objective of this paper was to analyse which documents and work methods of documenting processes within nursing are being used within different environments. Furthermore, what are the main reasons for their discrepancies from theoretical approaches and best practices. The analysis is based on a survey carried out on all three levels of healthcare. The survey questionnaire consisted of 12 questions to which responded 286 nursing teams from community health centres, hospitals and retirement homes in Slovenia. The results point to diversity in documenting as well as lack of interoperability. This is reflected in a great number of different documents. All phases of the nursing process were being documented in only 31.8 % of cases. The main reasons for this can be attributed to work organisation, different definitions of data-set requirements and inadequate knowledge by nurses. Survey results pointed out a need for the renewal of nursing documentation towards a more uniform system based on contemporary health technologies.
authors.affiliation: Faculty of Organizational Sciences, University of Maribor, Kidriceva cesta 55a, 4000, Kranj, Slovenia. uros.rajkovic@fov.uni-mb.si.
authors.forename: Uroš
authors.initials: U
authors.lastname: Rajkovič
authors.affiliation: Faculty of Health Sciences, University of Ljubljana, Poljanska cesta 26a, 1000, Ljubljana, Slovenia.
authors.forename: Marija Milavec
authors.initials: MM
authors.lastname: Kapun
authors.affiliation: Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.
authors.forename: Dejan
authors.initials: D
authors.lastname: Dinevski
authors.affiliation: University Medical Centre Ljubljana, Zaloska 2, 1000, Ljubljana, Slovenia.
authors.forename: Vesna
authors.initials: V
authors.lastname: Prijatelj
authors.affiliation: Faculty of Health Sciences, University of Ljubljana, Poljanska cesta 26a, 1000, Ljubljana, Slovenia.
authors.forename: Marija
authors.initials: M
authors.lastname: Zaletel
authors.affiliation: Faculty of Health Sciences, University of Ljubljana, Poljanska cesta 26a, 1000, Ljubljana, Slovenia.
authors.forename: Olga
authors.initials: O
authors.lastname: Šušteršič
mesh_terms: D004282:Documentation / Q000592:standards*; D057286:Electronic Health Records; D019538:Health Care Surveys; D009741:Nursing Staff, Hospital; D017524:Slovenia
keywords: Documentation; Information technology; Nursing