The Status of Nursing Documentation in Slovenia: a Survey.

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.

Toward the design of a nursing ontology system.

The unambiguous and consistent representation of the healthcare domain is the foundation of modernized healthcare (eg, electronic medical records). However, the nursing domain often fails to meet this requirement. In this article, we address this challenge by presenting a three-stage methodological approach that can be used to (1) capture knowledge in a nursing domain; (2) design a nursing ontology, composed of data models linked with terminology concepts in a multirelational property graph; and (3) implement and (4) evaluate the ontology. Through the feasibility, development, and evaluation phases of our methodological approach, we modeled a nursing domain (ontology) and the indices that partition the domain into an efficient, searchable space, where the solution to a nursing problem is seen as abstractly defined traversals through its graph vertices and edges. Thus, the use of the three-phase ontology development process and multirelational property graph was sufficiently comprehensive for achieving the representation of a nursing domain ontology and its instantiation.

A self-care process model for patients with chronic noncommunicable diseases.

Self-care of patients with chronic noncommunicable diseases is an essential component of contemporary healthcare. The purpose of this paper is to present a novel self-care process model and place it in the broader context of professional care. The extended Event-driven Process Chain approach to process modelling was used, focusing on a detailed overview of sequences of events, connections and activities and other elements/building blocks. A self-care process model was designed. The model is divided into two parts. The first part represents the self-care process when patients are able to manage their symptoms and be independent. The second part includes the process when patients are unable to perform self-care and/or need professional support. By identifying the essential elements of this process and incorporating them into the patients' care process, we can ensure that professional support for self-care creates a dynamic balance in the patients' ecosystems. Patients with chronic noncommunicable diseases need to make timely decisions about individual aspects of their health and seek professional help. In this way, an optimal level of health and well-being of patients can be achieved. Focusing on the patients' self-care process could also reduce treatment costs and improve the quality of life of patients. The novel designed model of the process of self-care, with all its essential elements, can be supported by digital technology, especially in the decision-making process and needs to become an important part of healthcare and long-term care systems.

Non-verbal communication of the residents living in homes for the older people in Slovenia.

Aging of the population is a growing problem in all developed societies. The older people need more health and social services, and their life quality in there is getting more and more important. The study aimed at determining the characteristics of non-verbal communication of the older people living in old people's homes (OPH). The sample consisted of 267 residents of the OPH, aged 65-96 years, and 267 caregivers from randomly selected twenty-seven OPH. Three types of non-verbal communication were observed and analysed using univariate and multivariate statistical methods. In face expressions and head movements about 75% older people looked at the eyes of their caregivers, and about 60% were looking around, while laughing or pressing the lips together was rarely noticed. The differences between genders were not statistically significant while statistically significant differences among different age groups was observed in dropping the eyes (p = 0.004) and smiling (0.008). In hand gestures and trunk movements, majority of older people most often moved forwards and clenched fingers, while most rarely they stroked and caressed their caregivers. The differences between genders were statistically significant in leaning on the table (p = 0.001), and changing the position on the chair (0.013). Statistically significant differences among age groups were registered in leaning forwards (p = 0.006) and pointing to the others (p = 0.036). In different modes of speaking and paralinguistic signs almost 75% older people spoke normally, about 70% kept silent, while they rarely quarrelled. The differences between genders were not statistically significant while statistically significant differences among age groups was observed in persuasive speaking (p = 0.007). The present study showed that older people in OPH in Slovenia communicated significantly less frequently with hand gestures and trunk movements than with face expressions and head movements or different modes of speaking and paralinguistic signs. The caregivers should be aware of this and pay a lot of attention to these two groups of non-verbal expressions. Their importance should be constantly emphasized during the educational process of all kinds of health-care professionals as well.

E-documentation as a process management tool for nursing care in hospitals.

Appropriate documentation plays a key role in process management in nursing care. It includes holistic data management based on patient's data along the clinical path with regard to nursing care. We developed an e-documentation model that follows the process method of work in nursing care. It assesses the patient's status on the basis of Henderson's theoretical model of 14 basic living activities and is aligned with internationally recognized nursing classifications. E-documentation development requires reengineering of existing documentation and facilitates process reengineering. A prototype solution of an e-nursing documentation, already being in testing process at University medical centres in Ljubljana and Maribor, will be described.

A new approach in nursing documentation: community nursing case.

This paper presents the development of electronic documentation for community nursing using a system approach. Documentation is viewed as an information model for organizing and managing processes. The community nurse plans the nursing process after gathering and evaluating information on the patient's health and his/her family status. Documentation is thus considered to be a basis for the successful work of the health team and as a way of ensuring quality in nursing. The paper describes a prototype software model for e-documentation in community nursing together with its evaluation in practice.

E-nursing documentation as a tool for quality assurance.

The article presents the results of a project with which we describe the reengineering of nursing documentation. Documentation in nursing is an efficient tool for ensuring quality health care and consequently quality patient treatment along the whole clinical path. We have taken into account the nursing process and patient treatment based on Henderson theoretical model of nursing that consists of 14 basic living activities. The model of new documentation enables tracing, transparency, selectivity, monitoring and analyses. All these factors lead to improvements of a health system as well as to improved safety of patients and members of nursing teams. Thus the documentation was developed for three health care segments: secondary and tertiary level, dispensaries and community health care. The new quality introduced to the documentation process by information and communication technology is presented by a database model and a software prototype for managing documentation.

A Model for Risk Assessment in Health Care.

The purpose of our research is to reduce risks and hence prevent errors in the health care process. The aim is to design an organizational information model using error prevention methods for risk assessment in a clinical setting. The model is based on selected indicators of quality nursing care, resulting from the world-known theoretical and practical models combined with experience in the Slovenian health care. The proposed organizational information model and software solution has a significant impact on the professional attention, communication and information, critical thinking, experience and knowledge.

The Integrated Patient's Self-Care Process Model.

Long-term care is more efficient and effective when it involves the active participation of the empowered patient and informal caregivers. To achieve this, it is necessary to guide the patient and informal caregivers through the systematic process of self-care. Well-documented observations and assessments are fundamental to plan further interventions of the interdisciplinary team. A systematic literature review revealed that the self-care process and the support of information technology are focused on just one chronic disease. Defined self-care process has a positive impact on the functionality and satisfaction of patients with comorbidity and on their caregivers. The model of the patient's self-care process should be an integral part of the long-term care.

Design of a Recommendation System for Adding Support in the Treatment of Chronic Patients.

Rapid growth of chronic disease cases around the world is adding pressure on healthcare providers to ensure a structured patent follow-up during chronic disease management process. In response to the increasing demand for better chronic disease management and improved health care efficiency, nursing roles have been specialized or enhanced in the primary health care setting. Nurses become key players in chronic disease management process. Study describes a system to help nurses manage the care process of patient with chronic disease. It supports focusing nurse's attention on those resources/solutions that are likely to be most relevant to their particular situation/problem in nursing domain. System is based on multi-relational property graph representing a flexible modeling construct. Graph allows modeling a nursing ontology and the indices that partition domain into an efficient, searchable space where the solution to a problem is seen as abstractly defined traversals through its vertices and edges.

Graph based model to support nurses' work.

Health care is a knowledge-based community that critically depends on knowledge management activities in order to ensure quality. Nurses are primary stakeholders and need to ensure that their information and knowledge needs are being met in such ways that enable them, to improve the quality and efficiency of health care service delivery for all subjects of health care. This paper describes a system to help nurses to create nursing care plan. It supports focusing nurse's attention on those resources/solutions that are likely to be most relevant to their particular situation/problem in nursing domain. System is based on multi-relational property graph representing a flexible modeling construct. Graph allows modeling a nursing domain (ontology) and the indices that partition domain into an efficient, searchable space where the solution to a problem is seen as abstractly defined traversals through its vertices and edges.

Supporting nurses' decisions with a multi-attribute model for patient health evaluation.

Nurses are required to make many important decisions, for instance on determining the level of the nursing problem, setting nursing diagnoses and interventions. The model presented in this paper is a tool for better and easier decision making is such situations. Multi-attribute modeling of patients' basic living activities is used for evaluation and explanation of their health status. It offers also visualization and quantification of the data which facilitate decision making in the framework of the process work method. The model can be viewed as an active check-list as it helps us reduce the possibility of "overlooking the queen on the chess board". The model was critically evaluated in practice.

An information system for community nursing.

In this article, an information system for community nursing is presented. It is critically evaluated on the basis of practical experiences. Its goal is not only to reduce the workload with modern information and communication technology but also to improve the quality of nurses' work. The quality improved because of the process method of work, which led toward a better client/patient orientation and more creative and research-oriented nurses' work based on nursing knowledge management support. It relies on an integrated and structured information picture, with special emphasis on transparency and interpretability.