Component documentationNursing

 

The Nursing module supports the nursing staff in the execution of a structured nursing process.

Nursing support in i.s.h.med is based on a structure which is oriented to the nursing process model.

Note Note

The use of a certain nursing model is not a prerequisite for implementing the i.s.h.med Nursing module. However, the models involving context-sensitive working aids, like the restriction of the available input help or automatic switching to the next work step, are then not possible.

End of the note.

Integration

The complete integration of the Nursing and Basis modules provides you with a transparent representation of medical and nursing orders and their transfer into nursing planning.

You can define and implement orders and nursing procedures individually or in cycles.

Features

  • Basic catalog entries

    For the nursing process model you enter basic catalog entries which you can use to compile standard nursing plans that simplify the entry of structured information. In the basic catalog entries you can describe the patient's resources, the nursing problems, the nursing goals, and the procedures.

    You can also combine standard nursing plans to form nursing plan profiles and insert these into the individual nursing plan.

    For basic catalog entries such as patient resources, nursing problems, nursing goals, procedures, and nursing services, you can use classification areas to map relationships between contents. These can be defined freely or to suit the nursing model and can then be used as contexts.

    Example Example

    For example you assign the resources "Patient can move freely in bed", "Patient can move freely about the room", "Patient can move about freely", to the classification area "Movement". In individual nursing planning for the resource "Patient can move about freely", you can limit the value selection for nursing problems and goals to smaller hit lists and selection lists. You can also use the standard nursing plans for diagnosis-oriented treatment schemes, for example, "Nursing care following a hip operation".

    End of the example.

  • Service catalog entries

    You enter nursing services in general service catalogs and indicate that they are nursing services.

    You can indicate that these services are relevant to billing or controlling.

    You can also combine nursing services to form nursing profiles.

  • Nursing anamnesis

    You can configure the nursing anamnesis as a parameterized document for the entire hospital or individually for the individual departments.

  • Nursing planning

    The nursing plan is used to plan nursing activities and shows in detail the patient resources, nursing problems, nursing goals, and procedures and other services.

  • Nursing worklist

    The nursing worklist provides an overview of the procedures or services for a patient within a selected period of time.

    In the nursing worklist you can perform, release, or cancel services, or create or change cycles for procedures.

    You can also print the nursing worklist and use this printout as a work paper for nursing staff at the patient's bedside.

  • Nursing overview

    The nursing overview offers an overview of the services to be performed or which have already been performed for all patients of a care unit.

  • Nursing printout

    The nursing printout serves as a work paper for nursing staff at the patient's bedside. The nursing staff enter the abbreviation of their name for the service which they have just performed on the patient.

    You can also use the nursing worklist as a work paper. This provides additional information about when the service should be performed.

  • Nursing report

    In the nursing report you document the effects of the performed nursing services, check the results, and enter supplementary documentation.

    Your hospital's code of procedure determines whether the medical record must contain hand signed documentation.

  • Transfer and/or discharge report

    Within the scope of parameterized documentation you can create a transfer and/or discharge report.