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Lecturer(s)
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Course content
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1. Introduction to the issue. The importance of documentation in healthcare. Legislation (Act No. 372/2011 Coll., on healthcare services, Decree No. 444/2024 Coll., on healthcare documentation), GDPR (Act No. 110/2019 Coll., on the processing of personal data). 2. Basic structure of healthcare documentation - personal, administrative, and clinical sections. 3. Electronic healthcare documentation (eHealth, ePrescription, NIS, data standards) - advantages and risks. 4. Nursing documentation - structure, data collection, care plan, recording standards. 5. Principles of record keeping - objectivity, chronology, comprehensibility, truthfulness, legibility, error correction, archiving. 6. Records in acute, long-term, and community care. 7. Legal aspects - liability, evidential value of records, errors in records, confidentiality. 8. Ethics and personal data protection in documentation. Patient consent, access to documentation. 9. International comparison - documentation in foreign healthcare systems. 10. Case studies and practical training - analysis of sample documentation, filling in documentation (case studies, error simulations).
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Learning activities and teaching methods
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- Contact hours
- 20 hours per semester
- Preparation for comprehensive test (10-40)
- 15 hours per semester
- Presentation preparation (report) (1-10)
- 8 hours per semester
- unspecified
- 10 hours per semester
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| prerequisite |
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| Knowledge |
|---|
| are not required |
| Skills |
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| are not required |
| Competences |
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| N/A |
| learning outcomes |
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| Knowledge |
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| describe the structure and content of healthcare documentation in accordance with Czech legislation |
| characterizes the differences between individual types of documentation (electronic vs. paper, nursing vs. medical) |
| Skills |
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| correctly and independently keeps records of the nursing care provided |
| identifies risks associated with improper record keeping |
| applies GDPR and ethical principles in care documentation |
| works with information systems used in healthcare |
| Competences |
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| N/A |
| teaching methods |
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| Knowledge |
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| Seminar |
| Skills |
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| Discussion |
| Task-based study method |
| working with documentation forms; simulations and case studies |
| Competences |
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| Seminar |
| Task-based study method |
| Discussion |
| assessment methods |
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| Knowledge |
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| Test |
| Skills |
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| Skills demonstration during practicum |
| preparation of a case study |
| Competences |
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| Test |
| Skills demonstration during practicum |
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Recommended literature
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Časopis Florence. .
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Časopis Zdravotnictví a medicína. .
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ISO normy týkající se dokumentace ve zdravotnictví.
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Sdělení č. 96/2001 Sb. m. s., o přijetí Úmluvy na ochranu lidských práv a důstojnosti lidské bytosti v souvislosti s aplikací biologie a medicíny: Úmluva o lidských právech a biomedicíně..
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Vyhláška č. 444/2024 Sb., o zdravotnické dokumentaci.
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Zákon č. 110/2019 Sb., o zpracování osobních údajů (GDPR)..
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Zákon č. 325/2021 Sb., o elektronizaci zdravotnictví..
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Zákon č. 372/2011 Sb., o zdravotních službách.
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Zákon č. 96/2004 Sb., o nelékařských zdravotnických povoláních.
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KUDLOVÁ, Pavla. Ošetřovatelský proces a jeho dokumentace. Zlín: Univerzita Tomáše Bati, Fakulta humanitních studií, 2016. ISBN 978-80-745-4600-6.
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POKORNÁ, Andrea; DOLANOVÁ, Dana; ŠTROMBACHOVÁ, Veronika; BUŘILOVÁ, Petra; KUČEROVÁ, Jana, et al. Management nežádoucích událostí ve zdravotnictví. Metodika prevence, identifikace a analýza. Praha: Grada, 2019. ISBN 978-80-271-0720-9.
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POLICAR, Radek. Zdravotnická dokumentace v praxi. Praha: Grada, 2009. ISBN 978-80-247-2358-7.
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7. VONDRÁČEK, Lubomír; WIRTHOVÁ, Vlasta. Sestra a její dokumentace. Návod pro praxi.. Praha: Grada, 2008. ISBN 978-80-247-2763-9.
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