Health Care Documentation Management in Hospital Conditions

1,2 Amer Ovčina
1 Selveta Mušanović
1 Ernela Eminović
2 Nada Spasojević
3 Amela Hajdarević
2 Jasmina Marušić

1 Clinical Center of the University of Sarajevo
2 University „Vitez” in Vitez, Faculty Health studies
3 Regional Medical Center „Dr. Safet Mujić” Mostar


Healthcare documentation or nursing documentation as often used in practice is the name of an indispensable part of a patient’s medical documentation, and documenta­tion is an integral part of a nurse’s daily work. Document­ing health care in the hospital means recording data on all procedures performed, during the entire health care process for the individual, all for the purpose of system­atic monitoring, planning and evaluation of the quality of health care. Nursing documentation serves as a means of communication between the team and is of great impor­tance for the quality and continuity of health care.

AIMS: 1 – To determine the existence of health care docu­mentation in hospital health care institutions; 2 – Exam­ine the importance and purpose of documenting health care among nurses-medical technicians; 3 – Examine the practice of nurses-medical technicians in the process of administering health care; 4 – Present quality indicators that are monitored and analyzed through health care documentation; 5 – Compare the obtained results in two examined areas.

METHODS: This research was conducted in two geographi­cally separate areas of Sarajevo and Travnik. The study in­volved 210 respondents, 147 nurses-technicians employed at the Clinical Center of the University of Sarajevo and 63 nurses-technicians employed at the General Hospital in Travnik. Data collection for research was carried out by exploratory and descriptive method. An original author­ized questionnaire was used for the descriptive research. The questionnaire was made available to respondents in the electronic form trough Google Forms. The anonymity of the respondents was fully guaranteed. The survey was conducted in the period from July 15- August 15, 2019.

RESULTS: At the Clinical Center of the University of Sa­rajevo (CCU), 98% of respondents use health care docu­mentation forms on a daily basis, and at the General Hospital Travnik 77.8% of respondents. In CCU Sarajevo, respondents use more standardized forms of health care documentation, 97.6%, compared to respondents in the General Hospital Travnik, where the documenting is car­ries out in nursing records, 74.6%. 68% of respondents at CCU Sarajevo believe that documentation contributes to the evaluation of nursing services, while only 19% of re­spondents at General Hospital Travnik believe the same. As the most common shortcomings, the respondents state the lack of computer technology in the department in 74.3%, then adequate premises for document adminis­tration in 37.6%, the lack of forms in printed form in 32.1% and 6 or 2.3% respondents did not answer this question.
In both institutions, the biggest shortcoming is the prob­lem of computer equipment in the department, in 70.7% in CCU Sarajevo and 82.5% in General Hospital Travnik.

CONCLUSIONS: The research found that over 95% of re­spondents use standardized health care processes in their daily practice, document health care, know the basic pur­pose and monitor health care indicators. More than 90% of respondents in both study groups use health care docu­mentation to plan health care and monitor its outcomes. More than half of respondents in both study groups stated that documenting health care is a problem because it consumes a lot of time. A larger number of respondents from both groups, as many as 30%, state that they do not use the data from the health care documentation for any purpose. The lack of workers in the health care process, insufficient knowledge of information technologies, and the lack of an information system represent an aggravat­ing circumstance in documenting the health care process.

Keywords: documentation, health care, nursing, practice, team­work, autonomy, laws.