Nursing Process Documentation
The Nursing Process Documentation component supports the nursing staff in the execution of the structured nursing process in the following steps:
The nursing process comprises the following steps:
The information is collected in the nursing anamnesis. The results of this flow into an individual nursing plan for a patient (nursing plan) and can preset the nursing plan with the aid of a Business Add-In (BAdI). You can find information on this BAdI in the documentation Customer-Specific Enhancements for Nursing Process Documentation.
The nursing staff execute the following activities in the nursing plan:
Entry of nursing problems and diagnoses
Determination of nursing goals
Planning of nursing procedures with cycles
The execution certificate for nursing services is made, for example, in the clinical work station using the worklist and the service entry function.
See Nursing Service Documentation in the Nursing Process Documentation
The nursing staff executes the evaluation in the nursing plan.
See Evaluations
Furthermore there is also the Nursing Progress Documentation, such as, for example, the Nursing Progress Report.
The most important dialogs which provide the nursing staff with all required functions of the Nursing Process Documentation component are:
A dialog for entering and processing nursing plans
A dialog for entering and processing nursing services
The clinical work station with the following view types:
Medication Events/Nursing Services
Occupancy, Departures and Arrivals
Outpatient Clinic/Service Facility
Furthermore there are also base items for the nursing plan and the nursing service, in order to be able to use both in the ward documentation work station. See Base Item
The Nursing Process Documentation component is available to you if you have activated the business function Clinical System Situation-Based Clinical Documentation (ISHMED_SCD).
The Nursing Process Documentation component especially supports the following processes in the inpatient nursing environment:
Admit Patient
The Plan Nursing Initially subprocess of the inpatient admission is part of the Nursing Process Documentation component and concerns activities such as, for example, structuring nursing problems and diagnoses, determining nursing goals, planning nursing procedures.
Care for Patient
The nursing process documentation component supports this process, for example, in preparing, executing and documenting nursing procedures, evaluating nursing planning, progress report.
Shift Changeover or Patient Transfer
The Nursing Process Documentation component provides all relevant information from your point of view.
Examplecurrent status from the nursing point of view (nursing problems, diagnoses, symptoms)
nursing-relevant entries from the progress report
planned nursing procedures or interventions
Prepare Physician Orders
Nursing procedures or nursing services can result from physician’s orders.
The Nursing Process Documentation component also covers the following requirements:
Fulfilling legal requirements in the documentation of nursing
This includes, for example, the Nursing Complex Procedure Score (PKMS) (DE) that is only relevant in Germany.
Mapping the nursing process, functional and primary nursing
You can find detailed information about this under Purpose.
Mapping nursing standards
Standard nursing plans and standard nursing plan profiles support nursing standards. Furthermore the system administrator can store URLs for any catalog entries such as, for example, nursing procedures, nursing goals. The nursing staff can read about, for example, treatment guidelines, best practices, there.
Solution with user-friendly interface and usability such as, for example, Drag & Drop
Flexible data model for any classifications, terminologies
In principle the system should be able work with any multiaxial nursing terminology and nursing language. Thanks to the flexible data mode the system can display various nursing classifications and terminologies.
Nursing plan as a separate entity, print function
The nursing plan can be used as an entity. This includes the nursing staff printing a nursing plan like a document and determining information such as, for example, who created the nursing plan and when, who ended the nursing plan and when.
Logical connections between nursing plan entries
The system administrator can connect basic catalog entries to each other in the master data. The system also displays these connections in the nursing plan.
Option of being able to enter further structured data, evaluation
Using the generic model of the basic catalogs the nursing staff can enter catalog entries as properties of other catalog entries in structured form. Moreover, the nursing staff can evaluate nursing plan entries.
Nursing in the outpatient clinic, i.e. outpatient nursing plans and nursing services in the outpatient clinic
Create nursing plans in the outpatient clinic
Enter nursing services in the outpatient clinic