Medical Documentation in the Care for a Minority Group Member

Abstract

Introduction: Nursing documentation is part of the patient’s medical documentation. It allows documenting the nursing care provided and at the same time gives much important information that healthcare professionals need to share among themselves. Aim: The aim of the research survey was to develop a draft of nursing documentation for patients from minority groups based on established specificities that may affect the care provided to members of minority groups. Method: Semi-structured interviews were conducted in order to determine the specifics of the selected minority groups. Questions for the semi-structured interview were compiled according to Larry D. Purnell’s Model of Cultural Competence. The areas that appeared most “problematic” in providing nursing care to patients – members of minority groups in healthcare facilities in the Czech Republic were identified based on open coding. In addition, a draft of nursing documentation was created based upon the results of interviews and using the Model of Cultural Competences as one of the inputs. Results: The following categories were included in the above-mentioned nursing documentation: communication, family, abuse, nutrition, spirituality, health care practices, care providers, pregnancy. Conclusion: The draft nursing documentation is such a tool that can be used for a quick and clear mapping and recording of the specifics in the various areas under consideration. The final form of nursing documentation for clients from minority groups in population is currently being reviewed for user-friendliness.