Folder Nursing General Structure

A rational way to address the design of a folder nursing care for a company, be it computer, paper or mixed content provides for the subdivision into two structural "macro areas". The first is a basic / common core, containing four modules (or parts divided, but the folder can not be separated) whose presence is necessary at all offices:
Personal data form;
Nursing History Form;
Form Care Plan;
Nursing Journal module.

The second macro-area is composed of a variable number of cards. Some of these are common in many situations, such as the registration of vital signs. Many others will be used only

occasionally or even should be designed on the basis of the specific operational context: For the control of respiratory cards, cards for the determination of the trauma, the water balance cards, cards with instructions for medication, evaluation boards Global assistance provided, cards for the transmission of the care plan to other teams, and so on. Each reality can decide how many and which cards to take, extending and customizing your own folder. The first four modules (Personal details, medical history, nursing care plan, nursing diary), may also be information only, and indeed, it is desirable that they are the computing power offered by the instrument, and will eventually be printed later, to store the folder with all its cards. An exception is the reality at home, where it is preferable that the diary is printed user to stay at home, as it should be updated and / or consulted by all the professional care team. During the hospitalization of the user every single card can be collected in folders or binders common, adapting to the working methods of the department. May be used where you need them: around visiting, shopping therapy, the medication cart. They can be left at home user, for example, during intravenous home therapies.

Folder Nursing Design

Each operating company should actually elect one or more referents that, even before active as a working group will analyze the forms already in use, assessing the possible non-compliance and / or structural deficiencies, in order to obtain not only a ' instant as more detailed documentation of their situation, but also a summary of the expectations and suggestions provided by colleagues. In the structural design and drafting, you should observe the following points:

Choosing a theoretical model. Indispensable for a correct formulation of the content, the choice of one of the many theories of nursing (or nursing ). We can consider, for example, the simplicity "model of nursing care" by Marisa Chanterelle , or completeness of the "functional models of health" by Marjory Gordon .

Preference for relevant data. Limit the information of "data collection" or tracking cards to those who really can affect the care process. The items "hobby" or "Religion", although certainly useful for a holistic understanding of the user, are unlikely to have feedback on nursing care. Likewise, an "emotional state" established at admission: hard to meet someone "Quiet".

Avoid duplication or unnecessary complications. In addition to full name of the user / client / patient and a possible identification number (or date of birth), one should not increase the demand on various boards of compilations that are obvious or duplication that could be made more easily. Simplicity is prerequisite for reliability. A simple structure is always preferable, because it improves: accessibility, readability, consistency, stability, and functionality.

Do not exceed the single page / screen. Is especially true for add-in cards, but also to the registry or medical history. Having the entire contents of a card at your eyes on a single sheet of paper or on screen, without having to leaf through other pages or click on the right and left with the mouse, is an incentive to smile.

Set the page with the synthesis and harmony. In the realization of media, whether printed pages or software applications, it is essential structuring a harmonious, orderly and condensed as possible. Every single page has to give the viewer the impression of having "everything under control" at a glance. The ideal would be to turn to graphics professionals.

Folder Nursing

The folder is a nurse on paper and / or computer system, which contains the recording of data and all documents pertaining to nursing on the case / user. Certifies and logically organized and effectively all the information and assistance activities of the person, collected and / or performed by ' nurses , fostering empowerment. It is used for writing history , for the definition of charitable objectives, for the annotation of the interventions and evaluation of results. The core of the folder is the nursing care plan customized. Formally recognized by art. 69 of DPR 384/90, is legally considered a public document, compiled by a person appointed as a public service. While not possess the same probative force, for greater completeness of health records to be stored as part of the medical record .

Premises

The 90s saw a proliferation of "nursing folders" with many different features. Initially placed all their attention to data collection, interviews with medical history, pre-compiled modules to be ticked and rating scales, but failed almost completely nullified the plan of care and, therefore, their main purpose. The folder is currently nursing a mature tool, which fully meets the criteria of effectiveness and efficiency required by companies, but arises from the need to fill a cultural void in those situations where no provision is made ​​for medical "problem oriented" (with annotations of different professionals in order, subject to individual user problems, communicating and interacting with each other). The recordings are therefore mainly "aimed at the source" (eg on printed forms with separate sections, reserved for professionals of different interventions, parallel to each other but not interacting). In addition to this, each operating reality then the document needs specific intensive care nurses, for example, have a need for additional documentation very different from that of a psychiatry nurses. After these premises, it is evident that you may encounter difficulties in conceiving and implementing a nursing business directory.

The transformational model of nursing practice

Among the goals that a modern and efficient health must ask what is the transformation of professional values, so that they. In terms of more nurses and coordinators should improve the quality of service so as to maintain or better to increase customer satisfaction and operators. This effort becomes more difficult because of cost constraints and the resources available are limited and strict.

The changes that require a higher priority are:
model that is sensitive to resource constraints, and select patients' needs. there is a two-way link between the rational use of staff and the quality of the service. is crucial to always give more room for creativity and the proposals made by operators. increased decision-making responsibilities of the coordinator, in collaboration with the patient.

The guidelines, procedures and protocols: the role of Nursing Coordinator

All operators, the primary nurse, they are required to follow some essential tools to coordinate action. They are: guidelines , procedures , protocols .

The Guidelines provide recommendations and guidance of clinical behavior whose purpose is to help stakeholders to decide on how best to apply in all circumstances. The guidelines do not restrict freedom of speech, but orient the choice of professionals.

In this context, the role of the coordinator is crucial. In fact, according to their knowledge and experience in the field, he must choose the most appropriate recommendations for each clinical case. They are classified according to five levels of scientific evidence (a, b, c, d, e) and, if it considers that none of these is valid and effective, may decide to edit them or create new ones. This decision is made, usually at the level of team work in which it is inserted. The procedures are internal rules of operation involving the activities of multiple people or functions. For the formalization process we understand a sequence of behaviors, however small, to standardize nursing activity. They are therefore examples of 'objects of Procedure': placement of a catheter indwelling in the adult male, the hygiene of hair in a person undergoing chemotherapy, as well as the interview at the time of nursing care of the client or the distribution of meals in an operational unit.

Even the ISO 9000 certification in health care has given rise to debates about the relationship between procedure and protocol: this is of more general, while the first is that part of the protocol which is used to detail the ways in which nursing takes place a certain action.

There are two types of procedures: those organizational, prepared under the supervision of the quality, and operational, written by professionals involved in the field and made operational by the directors of the department. Those of the second type take into account the legislation, guidelines and / or protocols of scientific societies. There are sometimes related to the procedures work instructions: These are detailed tasks, connected to specific situations. The procedures are approved by an Ipasvi based provincial / national level or through the national association of college of nursing.

The protocol, however, consists of a document that transfers at the level of professional conduct scientific knowledge gained. It is not, therefore, a statement of work, which takes care clinical content. The activity is divided into a sequence of behaviors: the operator remains free in the way in which to perform the individual steps, but this freedom must not compromise the consistency of performance.

The protocol is then encoded nursing course of action to be preferred in providing a given service in a given situation. The protocol can be considered as such only when, in its various components, is able to detail:

the patient's clinical situation for which the protocol can or must be activated;
the problem (or problems) pertaining to nursing that the protocol aims to address and manage and / or, again, the results to be achieved;
actions (which are also known in the literature acts, actions, behaviors, techniques, etc..) and the procedures to be activated;
indicators and standards for the evaluation of effectiveness.

The coordinator shall establish protocols that will be implemented in his department, assisted by a team of his choice. This work is done through the creation of ad hoc working groups, which he supervised, it is essential that the review, and any changes in procedural innovations are implemented with tight deadlines usually monthly.

Coordinator of Nursing

The coordinator is a professional nursing organization and material resources, both human ones, which coordinates, a business unit within a department or hospital, nursing all the figures.

Contributes to achieving organizational goals through a help function and stimulation of the members of his team, responds to the area coordinator and director of nursing. Collaborate in the drafting of guidelines, procedures and protocols. It combines professional management skills, leadership, and nursing skills.

The figure has become highly specialized with the Law February 17, 2006, No. 43. This law states that to become a nurse coordinator should have the following characteristics:

Master's degree in management for the coordination functions in the membership; at least three years experience in the membership profile. Is again recognized the valid certificate of competency to an executive position in nursing (courses for ex-nurse). Currently however, is not recognized the Master of Science in Nursing and Midwifery as the title to access the role.

Functions of the nursing coordinator
Guidelines (2001) provide training in the nursing coordinator for the acquisition of skills, as well as the promotion of lifelong learning and planning, even the direct management of training activities. The capacity to be developed include the identification of own training needs and those of his collaborators, the design and evaluation of training and testing the impact of training activities. The same Federation , in 2007, said that between the technical and professional skills that define the profile you are the Nurse Coordinator for the design, delivery and monitoring of training programs.

The nursing coordinator responds to the area coordinator and director of nursing.

Clinical Nurse Specialist

The Clinical Nurse Specialist (ISC) is an advanced practice nurse with a postgraduate training (clinical masters). The ISC is the expert clinician in the assessment and care planning area of ​​expertise, has a thorough knowledge of diagnostic and treatment of their patients, is able to develop their interventions according to the most recent indications of ' Evidence-based nursing . The ISC works with other nurses , encouraging growth and maintenance of nursing practice, to improve outcomes of patient care and build new care strategies.