Function documentationNursing Note

 

You use nursing notes to document the nursing treatment process of a patient during his/her inpatient stay.

You enter nursing notes as free text. Text modules are also available. Additionally, you can enter context information.

Prerequisites

  • The number range object for progress documentation is configured for the use of nursing notes. You can find information on this in i.s.h.med customizing under Start of the navigation path Industry-Specific Component Clinical System Next navigation step Clinical Documentation Next navigation step Progress Documentation Next navigation step Define Number Range for Progress Entries End of the navigation path.

  • If you want to use the nursing note in the ward documentation work station, a base item of the "progress entry" type must be configured. The base item must be assigned to a task and the task to a situation. You can find information on this in i.s.h.med customizing under Start of the navigation path Industry-Specific Component Clinical System Next navigation step Global Settings Next navigation step Base Items Next navigation step BAdI: Progress Entry Base Item Type End of the navigation path

  • An info item is configured for displaying the nursing progress report in the patient viewer (see template management, transaction N2WLD).

  • Cancellation reasons are maintained in customizing. For information about this, see i.s.h.med customizing underStart of the navigation path Industry-Specific Component Clinical System Next navigation step Cross-Application Settings Next navigation step Maintain Cancellation Reasons End of the navigation path.

  • In customizing you have maintained your own (main) categories and grouped these in category sets. You can then assign these sets to organizational units and occupational groups. The system will only then display the categories that are relevant for the given documenting unit, rather than all the defined categories, for selection. You can find information on this in the i.s.h.med customizing under Start of the navigation path INdustry-Specific Component Clinical System Next navigation step Nursing Process Documentation Next navigation step Nursing Progress Documentation Next navigation step Manage Categories End of the navigation path

Features

The nursing note is constructed as follows:

Environment Information

  • Organizational Data tab page

    If you have stored the base item with corresponding values for the documenting nursing and departmental OU and with the employee responsible, the system presets this data in the entry dialog of the inpatient progress notes. If no relevant data is available for the base item; the system presets the fields from the context of the documentation work station or from the user parameters.

    You can use the Display in Chart indicator to control whether the nursing note should be displayed in the chart.

  • Reference tab page

    Here you can set the nursing note in relation to a movement, a case or without reference. By default, the nursing note has a reference to the current movement. Using the Undo Reference pushbutton you can delete the reference. Using the Assign Movement and Assign Case pushbuttons you can set the reference. For this, the system displays the patient’s case list. The reference date and the reference time always constitute the creation date and creation time of the nursing note.

  • Log tab page

    Contains information about the user who created and changed the nursing note with the creation and/or change date and time, and the user who canceled the inpatient progress note with the cancellation date and cancellation reason.

Field for Specifying the Category

The selectable categories are available in the input help. The range of categories is dependent on the specified occupation group and its assigned category set.

Transfer-Relevant Indicator

Here you can determine whether the nursing note is relevant for transfer.

Free-Text Editor

You enter the text for the nursing note in the text field of the free-text editor. Here you are supported by the function for text modules that you access by choosing the identically named pushbutton, the context menu, or the input help.

Procedure

Enter or change the environment information and the category.

Enter the text for the nursing note in the text field of the free-text editor. You can edit the nursing note using the application toolbar.

When you choose Execute the system completes dependent fields.

Example: You enter the documenting nursing OU and choose Execute. The system determines the related documenting departmental OU, as far as this is unique.

Enter or cancel supplements for a released nursing note

Once released, a nursing note can no longer be changed. Using Enter Supplements you can create supplements for a released nursing note.

You can use the Display in Chart indicator to control whether the supplement should be displayed in the chart. While you are entering a supplement, you can display or hide the related nursing note and existing supplements for it by choosing Show/Hide Notes.

You can subsequently control the display of the nursing note and its relevant supplements separately in the chart.

You can cancel individual supplements. If you cancel the progress note, all related supplements are also canceled.

Authorization Check

You use the authorization object N_1NPND to control the authorization to display and edit nursing notes.