Specifics in the review of health documentation.

Abstract

The objective of the work was to identify if health documentation management is depending of actually current legislation. Also to review range and consistency records. The work described forms and content of documentation, relating to treat wounds and decubitus. A content analysis of 139 health documentation of insurer of General Health Insurance Company, which were treated by 28 home care agencies (hereinafter "HCA") and in the HCA was done directly audit in 2012 and 2014. We set 29 assessment items, with criteria separation according structure, process and outcome. Documentation, we analyzed three ways: through 5 grade rating scale, by choosing a clear answer to the question: yes, no and evaluation of specific items of documentation. The research confirm dependence keeping medical records in home nursing care agencies from legislation. On the other hand, it was found that the form of the recording method of health care in many cases are varied and fragmented. Deficiencies were found in the area of criteria such as structure, process and outcomes and transparency in the management of documentation pressure ulcers and chronic wounds. Only 62.9 % of the documentations was written nursing care and sent to Health Insurance Company in full compliance or with minor shortcomings. Research has shown that in the legislation defined by standard forms was recorded the lowest number of deficiencies. This fact needs to be used for the development of new legislation, which directed to setting documentation with clearly defined, structured information's. WHO adopted the International Classification for Nursing Practice (ICNP) as essential and complementary part of professional health services (Tab. 2, Fig. 2, Ref. 22).