Nursing Progress Documentation

The nursing progress documentation provides the nursing note and the nursing progress report.

You use the nursing note to enter information on the nursing progress of a patient in free-text note form. You can use text modules for this. You can structure the notes by assigning an occupational group and user-defined categories to them. Additionally, you can enter contextual information, such as the documenting organizational unit or the employee responsible.

You can also create a nursing note in the context of a procedure. The context cannot be selected if you create a nursing note, regardless of a procedure, e.g. in the clinical work station or documentation work station.

The nursing progress report supports this form of medical documentation by displaying the various notes together chronologically. You can use filter functions to create special views of the nursing progress report.

Note Note

If you wish to use the nursing report of the Nursing component instead of the nursing progress note of the Nursing Process Documentation component, the system administrator must set the organizational unit-related parameter (OU parameter) N1NRSNOTE to the value “O”.

End of the note.

The authorization object N_1NPND prevents unauthorized access to your data.

Implementation Considerations

In i.s.h.med the progress documentation is available, in addition to the nursing note and nursing report function, for entering and displaying notes concerning the treatment progress of a patient. If you configure the i.s.h.med progress documentation, you replace the nursing note function. For more information, see i.s.h.med progress documentation.

Integration

Use in the Ward Documentation Work Station

The nursing note is available in the ward documentation work station as a documentation object, which is connected with a task via the base item. In the base item you can configure whether the connected task is automatically completed when the nursing note is released. The nursing progress report is displayed in the patient viewer.

Use in the Patient Organizer

The nursing note is available as an independent standard aspect of the patient organizer. The individual notes are displayed in tabular form in the standard aspect. The complete set of notes is output as a nursing progress report in the detail window of the patient organizer.

You can edit the individual nursing notes using the functions of the patient organizer.