Kvaliteta i opseg podataka u medicinskoj dokumentaciji u maksilofacijalnoj kirurgiji koju specijalist upućuje liječniku primarne zdravstvene zaštite

master's thesis

• Title (english): Quality and quantity of medical data send by specialist to general practicioner
• Author: Kristina Kolar
• Mentor: Narandža Aljinović-Ratković (mentor)
• Committee member: ŽELJKO ORIHOVAC (predsjednik povjerenstva)
• Committee member: Ivica Lukšić (član povjerenstva)
• Committee member: Narandža Aljinović-Ratković (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; (Department of Maxillofacial Surgery and Dentistry); Zagreb
• Defense date and country: 2015-07-15, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences; Surgery

Abstract

Medicinska dokumentacija predstavlja zapis kliničkih postupaka i njihove uspješnosti te je osnova kontrole kvalitete svake zdravstvene ustanove. U medicinskoj dokumentaciji otpusno pismo je jedinstven i uniforman dokument koji dobiva svaki bolesnik koji boravi u bolničkoj ustanovi. Otpusno pismo je važno jer sadrži esencijalne informacije koje specijalist upućuje liječniku opće medicine o bolesniku nakon liječenja u bolnici. Unatoč važnosti otpusnog pisma u svakodnevnoj praksi zasad ne postoje pravila i smjernice glede sadržaja OP. Sadržaj OP dosad nije standardiziran među bolničkim ustanovama. Cilj ovog diplomskog rada bio je analizirajući medicinsku dokumentaciju procijeniti kvalitetu, opseg i zastupljenost pojedinih podataka u otpusnim pismima KKČLU. Kao ispitivani uzorak korišteno je 100 OP pacijenata na bolničkom liječenju u KKČLU. Za analizu je uzeto svako dvadeseto OP iz razdoblja 01. 01. 2013 – 31. 12. 2013. godine iz bolničkog informacijskog sustava. Za procjenu adekvatnosti izabrana su mjerila zastupljenosti informacija o dijagnozama, anamnezi, statusu pacijenta, liječenju, decursusu morbi, preporukama i uputi za kontrolni pregled. Rezultati su pokazali optimalnu zastupljenost podataka u: 85 % OP o decursusu morbi, 76 % OP o uputama za kontrolni pregled, 58 % OP o liječenju, 56 % OP o preporukama, 27 % OP o dijagnozama i 15 % OP o anamnezi i statusu pacijenata. U raspravi se obrazlaže zašto pojedine stavke OP KKLČU pridobivaju više pozornosti prilikom pisanja te zašto niski postoci zastupljenosti pojedinih podataka ne znače i lošu kvalitetu OP. Na kraju se iz dobivenih rezultata zaključuje da postoji potreba za razvoj predložaka, preporuka i smjernica za pisanje otpusnih pisama u svrhu podizanja njihove kvalitete.

Abstract (english)

Medical documentation is a record of clinical procedures and their success and the basis for quality control of every medical facility. Discharge summary (DS) is unique and uniform document that is given to every patient who was treated in medical facility. Discharge summary is important because it contains essential informations that specialist sends to general practitioner about patient's treatment in the hospital. Despite the importance of the discharge summaries, in daily practice for now there are no rules and guidelines concerning the content of DS. Writing of DS is not standardized among medical facilities. The aim of this graduation thesis was to analise medical documentation and to evaluate the quality, quantity and distribution of data in DS at „Clinic for head and neck surgery“ at University Hospital Dubrava. As the sample were used 100 DS. For the analysis was chosen every twentieth DS from period of 01.01.2013 to 31.12. 2013. from the Hospital Information System. Every DS was assessed for the adequacy of information about diagnoses, past medical history, status of the patient, treatment, decursus morbi, recommendations and instructions for next check up. The results showed that informations were optimaly written in: 85 % DS about decursus morbi, 76 % DS about check up, 58 % DS about treatment 56 % DS about reccomendations, 27 % DS about diagnoses and 15 % DS about medical history and status of the patient.
In the discussion, it is explained why certain parts of DS are given more attention when surgeon is writing it, and why small percentages of representation of certain information does not mean poor quality of DS. Finally, the results led to conclusion that there is a need to develop templates, recommendations and guidelines for writing DS in order to raise their quality.

• Keywords: otpusno pismo; maksilofacijalna kirurgija; otpust; medicinska dokumentacija
• Keywords (english): discharge summary; maxillofacial surgery; discharge; medical documentation
• Language: croatian
• URN:NBN: urn:nbn:hr:105:538176
• Study programme: Title: Medicine; Study programme type: university; Study level: integrated undergraduate and graduate; Academic / professional title: doktor/doktorica medicine (doktor/doktorica medicine)
• Type of resource: Text
• File origin: Born digital
• Access conditions: Open access
• Created on: 2016-08-09 08:51:53