E-nursing documentation as a tool for quality assurance.

Area of Science:

• Nursing Informatics
• Health Information Management
• Healthcare Quality Improvement

Background:

• Nursing documentation is crucial for quality healthcare and patient treatment.
• Existing documentation methods may lack efficiency in tracing, transparency, and analysis.
• Standardization of nursing documentation is needed across diverse healthcare settings.

Purpose of the Study:

• To reengineer nursing documentation for improved quality and patient safety.
• To develop a new documentation model based on Henderson's 14 basic activities of living.
• To integrate information and communication technology into nursing documentation processes.

Main Methods:

• Reengineering of nursing documentation processes.
• Application of Henderson's theoretical model of nursing.
• Development of a database model and software prototype for documentation management.
• Implementation across secondary, tertiary, dispensary, and community healthcare settings.

Main Results:

• The new documentation model enhances tracing, transparency, selectivity, monitoring, and analysis.
• Improvements observed in overall health system efficiency.
• Enhanced safety for patients and nursing team members.
• A functional software prototype for managing reengineered documentation was developed.

Conclusions:

• Reengineered nursing documentation, supported by ICT, significantly improves healthcare quality and patient safety.
• The new model provides a transparent, traceable, and analytical approach to patient care.
• The developed system is adaptable to various healthcare segments, promoting consistent standards.