Folder Nursing Journal module nursing

Effectively replaces the traditional "delivery", where the ' nurses at shift end, summarizing a large agenda of the conditions of the users, the interventions performed on them, and any other event worthy of note.

A nursing paper diary can be composed of pages numbered in sequence with the usual name, first name and identification number (or date of birth), and even simple layout lines, by providing more in sequence to score the date, time, comments and acronym of ' nurses compiler.

Even in this case will indicate the most significant changes in the conditions of the user, the objective and subjective data, and all the possible problems that may affect the welfare plan of care . It is not necessary to bring back to diary operations and activities that are performed routinely, such as: administration of therapy to time, blood tests or X-rays.

Instead should be reported: drugs administered 'as needed', x-rays or tests performed outside of the routine, such as investigations of falls or malaise. Avoid writing things that are absolutely useless, typical of the old "delivery".

If you pass the afternoon reading a book, you do not need that ' nurses write in his diary: "Still Afternoon."

Folder Nursing Form Care Plan

Contains the written formulation of the entire nursing process , the aims and objectives of the services provided to the user, based on the needs identified and diagnoses derived from these. Evaluate the residual capacities of the individual and determines the activities required to attain the set goals, expressed in terms of expected results.

Be drafted in a clear, flexible, well-defined, must consider the human and material resources available and should include the criteria for evaluating the effectiveness of the intervention (performance indicators). Apply the scientific method of problem solving ( problem solving ) and used as a starting database of the history of nursing.

Graphically it can be summarized into four "pillars": nursing diagnosis (or problem related to the need), Objective (expected result in the short, medium or long term, with the adoption of performance indicators), Intervention (related to the problem and made ​​dependent on 'objective, planned activities in the individual and at the time of execution) and Verify (analysis of performance indicators and possible return to the previous phases, with the reassessment of objectives and interventions).

In some areas, such as emergency room (where the speed of action is essential to ensure health same user), or as the specialist clinic (where you are stationed only a few minutes), the possibility of establishing a care plan with its history is absolutely out of question.

However, a team that works in these areas of care plans can use "pre", in the form of standardized procedures or simple operating instructions, which, while not reaching the level of sophistication and customization tool that would allow, enable a practical response, perhaps essential and minimalist, but correct in its application and more effective.

Folder Nursing History Form

Place where you collect the data considered relevant to the identification of needs and residual abilities. Almost impossible to practice in some hectic work environments, it is also the most difficult to design. In order not to turn the investigation into a mere exercise, then not being able to use it on the field, you must decide very clearly what we really need.

The conceptual model helps us a lot, but it can distract from the real issue, shifting the focus of the compiler on issues of little importance. It is likely that the draft requires two or more printed pages. This is different from the medical history, however, like the latter, may be recorded in an "unstructured", ie by writing their observations on a simple sheet of paper (perhaps using a lookup table in which to choose data collection).

But this gives rise to two problems, related to the skills of individual nurses and the inability to use, then the data in computer. A data collection with multiple-choice items to be ticked, in addition to greatly simplify the lives of those who work in the department (where the pace of work and the environments do not allow space for reflection), allows entry into a relational database like SQL and then a subsequent revision of statistical data. There are dozens of rating scales that could be used to enrich the "Nursing History Form." There are lots of useful but not essential.

If the resulting score is an indication for any influence with the care process, well, otherwise they are only further loss of time. Instead, they can be very useful planning tools that allow you to calculate the workload.

Folder Nursing Personal information Form

In the paper version also serves as a "container", as usually placed on the cover of the folder. With the software version but will require an additional interface, a first screen that functions from the main menu to be able to move within the contents of the folder. In this case the screen with their personal data will be accessible by indicating the name of the user, and is likely to exploit a database company, with the basic content that will be supplemented or corrected during the interview (always check the address and numbers phone). Are transcribed medical diagnoses known if verified (obtained from medical records , or communicated by the physician), invalidating any conditions, allergies notes that, for methodological correctness, should be recorded in "Nursing History Form", but given their importance is always preferable to place them in the "front page". Better is always well marked, so that no operator make some

errors (eg, not realizing that someone is diabetic or allergic to kiwi fruit). If the folder is at home, also evaluate the condition of family housing functions and the presence of media and social welfare. This may indicate a relative reference to the need to contact or, in the home, a care-giver who will serve as an alternative to ' nurses in the process. Always consider an area "Notes", useful for all events and contingencies.

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.