B. Prinčič
Marand inženiring d.o.o., Ljubljana, Slovenija

M. Purkart
Pediatrična klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija

M. Oštir
Služba za pljučne bolezni, Pediatrična klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija

A. Štih
Služba za neonatologijo, Pediatrična klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija

Abstract

Documentation of nursing care is an important part of the complete patient health records. It presents documentation of individual phases of the nursing process. It has an impact on the provision of continuous and quality health care, communication between members of the medical team and can be a basis for research. In the era of the „explosion“ of technology in the medical profession, nurses more and more use information technology in the field of nursing in order to reduce errors and work overload. These technologies include electronic documentation of patient status and nursing activities, reading bar codes, speech recognition systems, the use of Tablet PCs and the use of medical information standards, including the openEHR, IHE and HL7/CDA, ensuring rapid and complete integration of healthcare information systems and medical devices.

Key words: nursing, nursing documentation, nursing process, electronic nursing documentation, electronic patient record.