680 Organizacija, letnik 39 Razprave številka 10, december 2006 A Model of E-documentation of Community Nursing Uroš Rajkovič 1 , Olga Šušteršič 2 , Jože Zupančič 1 1 University of Maribor, Faculty of Organisational Sciences, Kidričeva cesta 55a, SI-4000 Kranj, Slovenia, uros.rajkovic@fov.uni-mb.si, joze.zupancic@fov.uni-mb.si 2 University of Ljubljana, College of Health Studies, Poljanska cesta 26a, SI-1000 Ljubljana, Slovenia, olga.sustersic@vsz.uni-lj.si This article presents the development of electronic documentation for community nursing using a system approach. Documentation is viewed as an information model for organizing and managing processes. The community nurse plans the nursing process after gather- ing and evaluating information on the patient’s health and his/her family status. Documentation is thus considered to be a basis for the successful work of the health team and as a way of ensuring quality in nursing. The article describes a prototype software model for e-documentation in community nursing together with its evaluation in practice. Key words: nursing, community nursing, modelling, documentation, software solution Model e-dokumentacije zdravstvene nege v patronažnem varstvu Prispevek predstavlja sistemski pristop k oblikovanju elektronske dokumentacije zdravstvene nege v patronažnem varstvu. Dokument- acija predstavlja informacijski model, ki je namenjen organiziranju in upravljanju procesov. Na osnovi informacij, zbranih z ocenjevanjem zdravstvenega stanja pacienta oz. stanja razmer v družini, medicinska sestra načrtuje proces zdravstvene nege. Dokumentacija je temelj za uspešno delo zdravstvenega tima pa tudi element zagotavljanja kakovosti zdravstvene nege. V prispevku bo opisan prototipni model informacijske rešitve za izvajanje e-dokumentacije v patronažnem varstvu. Ključne besede: zdravstvena nega, patronažno varstvo, modeliranje, dokumentacija, programska rešitev 1 Introduction A system approach in the organizational and informational context brings specific challenges in terms of the complete management of complex systems (Kaplan, 1997). Systems in healthcare, of which nursing is a part, similarly belong within this framework (Taylor, 2001; Van Bemmel and Musen, 1997). Along with the system approach, it makes sense to use the potentials of contemporary information and communications technology (ICT) and to study the possibility of adding value in managing complex systems, especially in terms of the effective use of resources and qual- ity assurance. E-documentation of any process is an information model, which uses ICT for organizing and managing the process according to established goals. Nursing documenta- tion consists of patient and family data. Nurses use these data to plan the nursing process, which in short covers assess- ing patient’s nursing problems, making nursing diagnoses, implementing nursing interventions and evaluating the work (Gordon, 1994; Taylor et al., 2001). The documentation of the nursing process is the basis for the successful work of a nurse, and also represents an element of quality assurance in nursing (Ball et al., 2000; Rajkovič et al., 2000; Saba and McCormick, 2000; Potter and Griffin Perry, 2003). Existing nursing documentation mainly consists of words, and only rarely includes graphs and pictures. It provides a data set that serves as a base for a software solution (Šušteršič et al., 2002; Klein, 2003). As long as such documentation is kept manually, ICT possibilities are not exploited. It makes sense to use object-oriented approach to the reengineer- ing of documentation into electronic form (McFadden and Hoffer, 1994; Barry, 1996; Kroell & Birthe Garde, 2005), which enables more suitable structuring and processing of data in electronic form. It is thus a matter of structuring the documentation in terms of an object orientation, whereby classical data are combined with models and procedures for their implementation, e.g., graphic presentation of numeri- cal data (Kaplan 1997). At the same time, when reengineer- ing the documentation, possibilities and needs appear for the reengineering of basic processes (Jacobson et al., 1994; Ferioli, Migliarese, 1997; Chang, 1999; Meystel and Albus, 2002) in the organisational sense, in this case in the field of nursing. We wish to propose a model that will serve for the reengineering of classical documentation into e-documen- tation. With a suitable object-oriented organisation and use of contemporary ICT it is thereby possible to achieve a higher level of quality especially in regard to integral treat- ment of the patient. The active computer model itself sup-