Edit Nursing Notes in Patient Organizer

You use the nursing note to enter information on the nursing treatment process 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.

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

The authorization object N_1NPND prevents unauthorized access to your data.

Integration

The nursing note is available in some standard aspects of the patient organizer (Quarter, Case, Total) as well as in its own standard aspect (SAP39). The patient organizer’s overview display shows the individual notes as the nursing progress report. The complete set of notes is also displayed as the nursing progress report in Web Dynpro technology in the patient organizer’s detail window.

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 Progress Documentation Define Number Range for Progress Entries End of the navigation path .

Features

The following functions are available for processing nursing notes:

Create

You create nursing notes for a patient using Start of the navigation path Create Next navigation step Nursing Note End of the navigation path in the patient organizer or by using the context menu on an existing entry.

Note Note

To work with the context menu, you must select an entry by clicking the icon in front of the entry.

End of the note.

You can enter the note in a free-text editor in the input dialog. You can also enter context information for the note. This information is preset with the context data of the patient organizer but can be changed.

Organizational Data Tab Page
The current OU from the context of the patient organizer is preset as the documenting nursing and departmental OU.

The EmR contains the contents of the user parameter VMA.

You can use the Display in Chart indicator to control whether the nursing note should be displayed in the chart.
Reference Tab Page
The movement reference is preset as standard. The system determines the current movement from the context of the patient organizer. The reference date and the reference time are always the creation date and the creation time of the inpatient progress 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 a 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.

The Entry Dialog

The following functions are available via pushbuttons in the entry dialog:

(-)	Execute Enhancements	Enhances dependent fields such as the documenting departmental OU for an entered documenting nursing OU as far as this can be uniquely determined
(-)	Save	Checks and saves the nursing note.
(Save+Close)	Save + Close	Checks and saves the nursing note and closes the entry dialog.
(-)	Release + Close	Checks and saves the nursing note, sets the release indicator and closes the entry dialog. The release of the nursing note cannot be undone, released documents cannot be changed.
(-)	Print	Prints the nursing note.
(-)	Cancel	Closes the input dialog without saving.
(-)	Enter Supplement	Creates a supplement for a released and no longer changeable nursing note.
(-)	Hide/Show	Shows or hides associated nursing notes/supplements while you enter the supplement.
(-)	Text Module	Calls the selection list of the text modules. Using subfunctions you can create, insert, and manage text modules and call markers.

The patient organizer’s function buttons make the following functions available to you:

Change

In order to change a nursing note, select it and choose (-) (alternatively using the context menu). You can only change nursing notes that have not yet been released.

To enhance a released nursing note, you can enter a supplement. You can use the Display in Chart indicator to control whether the supplement should be displayed in the chart.

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

Display

The system will display the nursing notes as the nursing progress report in the detail screen of the patient organizer.

To view a nursing note, select an entry in the patient organizer’s overview display (alternatively using the context menu or choose (-)). In a Web Dynpro view you see all the nursing notes in chronological order, the most recent nursing notes at the top. The nursing note selected in the overview display is shown in the detail window focused in the highest position. If the list is not completely visible in the detail window, you can quickly navigate to all nursing notes using the scrollbar.

You can modify the scope of data displayed by using the column set (context menu on the nursing progress report).

To include all nursing notes in the overview, the system displays the first 50 characters of the note text. The popin function of web dynpro technology is available for displaying extensive text. Using Open/Close Notes you can open or close all the texts at once.

Using Set Filter you can create special views of the nursing progress report (for example, all nursing notes that were entered by the occupational group Nurse or all nursing notes in a specific context).

Communication exists between the nursing notes in the overview display and the nursing progress report in the detail view. This means that the system displays a nursing note selected in the overview as focused in the nursing progress report and with opened popin. Sorting and filtering in the overview display has no effect on the nursing progress report, and vice versa.

Cancel

You can cancel nursing notes using (-) or the context menu. To do this, select the nursing note that you wish to cancel in the patient organizer’s overview display. Those supplements assigned to the note are also canceled at the same time.

Note that the system can cancel several selected entries using the Cancel function called using the context menu. You should also note that the function call is restricted to the selected entries of one object type.

Print

To print one or more nursing notes, select them in the patient organizer’s overview display and choose (-).

Release

You can release nursing notes by using (-). To do this, select one or more nursing notes in the patient organizer’s overview display.

Note that the system can also take into consideration additionally selected clinical orders using the Release function called using the context menu.

Note Note

You can only use the Release function for services, documents and progress entries. You should note that the function call is restricted to the selected entries of one object type. This means that you cannot, for example, simultaneously select documents and services and call the Release function.

End of the note.