Nursing Report
In the nursing report, you can enter user-defined nursing texts. This text entry is case-related and is chronological.
You can call the nursing report on a context basis from the clinical work station, or in the clinical system (
Clinical Documentation
Document
or Document List
). You make the clinical work station settings in the function variant.
For information about how to process an entry, see Writing a Nursing Report.
Prerequisites
Your system administrator must have set up and configured the nursing report in order for you to be able to use it. For information about this, see Setting Up the Nursing Report and Configuring the Nursing Report.
Nursing Report Content
The nursing report contains case-related data for a patient and the following attributes for each entry:
Nursing report date |
Date to which the entry relates |
Nursing report time |
Time to which the entry relates |
Employee responsible |
Employee responsible for the documentation |
Nursing report entry |
Text of the nursing report |
A canceled entry is indicated by the word Canceled
(red).
A subsequent entry is indicated by the word Supplement
.
Presetting the Employee Responsible
When you make a new entry, the system presets the Employee Responsible
from the user profile if the VMA user parameter is maintained there. If a nursing report entry is not released when you call the nursing report, the system presets the Employee Responsible
with the last user.
Nursing Report Functions
The nursing report contains the following functions that can execute using the corresponding pushbuttons:
Release Documents
The nursing report is set up as a document category in such a way that a case reference is always required for documentation. You can only release the document after discharging the patient. Once the nursing report has been released, it can no longer be changed. The nursing report documentation can thus only be entered between the admission date and the discharge date of the respective case.
Movements
This function provides an overview of all movements for a case (case list).
Release Entry / Create Supplement
This function releases the entry which you are currently processing. Once an entry has been released, it can no longer be changed. This ensures that existing documentation cannot be modified retroactively.
When you release the entry the system checks whether the nursing report date of the current entry is before the nursing report date/time of the entry released last. If this is the case, the entry is flagged as a Supplement
. You must save the nursing report following the release.
Cancel Entry
You can cancel individual entries in the nursing report. You can only execute this function for released entries. Click an entry and choose 
(Cancellation
).
Display Canceled / Hide Canceled
You can use these functions to display and hide canceled report entries in the display area.
Call Nursing Plan
Using 
(Nursing Plan
) you can call the individual nursing plan for the case directly from the nursing report. The last inpatient stay of the case will be taken into account. When you exit the nursing plan you automatically return to the nursing report.
Information
This function provides information about the technical management data of an individual entry in the nursing report. The system provides the name of the user, who created, changed or canceled the entry, and the date.
(-
) expands all nursing report entries.
(-
) collapses all nursing report entries.
You can expand and collapse an individual entry in the tree view using the arrow and, in the HTML view using + and -.
In the editor area you can use and process text modules via the context menu.
Switch Additions On / Switch Additions Off
Depending on how you called the nursing report, a specific set of nursing report entries is displayed:
If you called the nursing report document without a context, i.e. using document management only entries without a context reference are displayed.
If you called the nursing report document with a context, i.e. using the nursing documentation (e.g. from the nursing plan), the system will only display entries which belong to the current context.
Using 
(Additions On
) and 
(Additions Off
) you can show or hide all the remaining nursing report entries of the patient:
In the case of the context-free nursing call, the function controls whether additional context-related nursing report entries are displayed.
In the case of the context-related nursing call, the function controls whether additional context-free nursing report entries are displayed.
The pushbutton is only available if more nursing report entries exist.
All for Type On / All for Type Off
If you have called a nursing report document for a procedure in relation to a context, you can use (All for Type On
) and (All for Type Off
) to show and hide all nursing report entries – for multiple nursing plans – for the nursing report type Procedure of the patient.