Analýza zdravotnických dokumentací na zdravotnické záchranné službě České republiky
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Abstract
Výjezdové základny zdravotnické záchranné služby na území České republiky využívají rozdílnou strukturu zdravotnické dokumentace, konkrétně tzv. Záznam o výjezdu. Legislativa udává povinnost vyplnit zdravotnickou dokumentaci, avšak nezahrnuje její ucelenou formu. Dokumenty sice plní účel identifikace pacienta a jeho zdravotního stavu, nicméně právě ona neucelenost tohoto systému v praxi může přinášet nesoulady v případech kooperace zdravotnického personálu z různých zařízení. Teoretická část se zabývá vymezením pojmu zdravotnická dokumentace, její charakteristikou a právními předpisy s ní souvisejícími. Výzkumná část je zaměřena na zjištění výhod a nevýhod využívání různých druhů zdravotnických dokumentací. Výstupem této práce je návrh výukové dokumentace pro studenty studijního oboru zdravotnický záchranář.
Throughout the different regions of the Czech Republic the emergency ambulance service uses a system known as Ambulance Patient Records to record patients details and medical history. Current legislation clearly states the need for this documentation, however there is no unified version of it in existence. Therefore it is rather unclear as to how these documents should look like in terms of structure and content. Existing documents currently provide information regarding patient's health status, but due to the different versions of the Ambulance Patient Records in various regions, difficulties in communication and informational transfer may have occurred when two teams from different regions work alongside each other. As a result of the above, this thesis produces simplified documentation template for educational purposes, standardising records, meaning that all paramedic students are equipped to work from any ambulance base in the country. The theoretical section of this thesis focuses on what the definition of medical documentation actually represents and stipulates its legislative boundaries/characteristics. Furthermore, the research section explores the pros and cons of using different records and the impact that this has on current paramedic students in position of future job applicants as well as on employees of the Czech health care systém.
Throughout the different regions of the Czech Republic the emergency ambulance service uses a system known as Ambulance Patient Records to record patients details and medical history. Current legislation clearly states the need for this documentation, however there is no unified version of it in existence. Therefore it is rather unclear as to how these documents should look like in terms of structure and content. Existing documents currently provide information regarding patient's health status, but due to the different versions of the Ambulance Patient Records in various regions, difficulties in communication and informational transfer may have occurred when two teams from different regions work alongside each other. As a result of the above, this thesis produces simplified documentation template for educational purposes, standardising records, meaning that all paramedic students are equipped to work from any ambulance base in the country. The theoretical section of this thesis focuses on what the definition of medical documentation actually represents and stipulates its legislative boundaries/characteristics. Furthermore, the research section explores the pros and cons of using different records and the impact that this has on current paramedic students in position of future job applicants as well as on employees of the Czech health care systém.
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zdravotnická dokumentace, zdravotnická záchranná služba, zdravotnický záchranář, povinná mlčenlivost, ambulance patient records, emergency ambulance service, paramedic, obligation of secrecy