NURSING PROCESS AND DOCUMENTAION

Content

Subject carrier

Description

1. Patient’s treatment according to the nursing process (phases, standardised forms for the description of nursing process)
2. Clinical pathway (relation between clinical pathway and nursing process, forms for the description of clinical pathways, standards and recommendations)
3. Development of nursing documentation
4. Classifications of nursing practice (e.g. NANDA, ICNP and their translation in Slovene)
5. Definition of nursing diagnoses, outcomes and nursing intervention
6. Relation of nursing process with other processes in healthcare environment
7. The importance of informatisation of nursing process and entire clinical pathway

8. Modern approaches of nursing process e-documentation and other processes directly related to nursing

9. Nursing information systems and their relation with other healthcare information systems and other healthcare system stakeholders
10. The importance of nursing practice classifications for the informatisation
11. Development of nursing information systems (definition of requirements for the information system, design of the prototype, the importance of nurses’ participation in the development phase, testing phase)

12. Modern information and communication technologies (ICT) in the support of nursing (e.g. web technologies, modern user interfaces, review of current implemented solutions) and criteria for their selection

13. Overview of the plans regarding e-documentation in nursing (strategic goals, visions and directions of Slovenia and EU in this field, electronic health record, nursing health record), legal standing and current standards in the field of e-documentation in nursing
14. Information security
15. Review of best practices in the field of nursing e-documentation (examples from the primary, secondary and tertiary health care level and social welfare institutions).

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