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Nursing Care and Management

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The module should handle all the processes involved in the daily transactions that occur in a ward, these transactions involve test requisitions placed for the patient, medicines consumed by the patient, bedside procedures performed, medical equipment connected to the patient , and recording of all visits by the doctor.
Furthermore, the nursing module should allow for the capturing of nursing assessment data, nursing plans and checklists, nursing charting/progress notes, nurse management / rostering and nursing quality assurance. All of these are essential as the patientís physical condition throughout the hospital stay needs to be recorded, nursing plans and checklists would help in the quality of care provided by nurses as well as the effective management of nursing resources throughout the hospital.
The application should enable managers and heads of all groups to create detailed, accurate, on-line work schedules for their staff. The required software should provide all information necessary to simplify staffing and scheduling.
Authorized schedule makers should be able to experiment with draft schedules on-line before creating a final schedule.
The following has been extracted from a recent RFP. I've included it here for your reference. It may prove useful for anyone preparing such a document.
Please feel free to comment on this list, and propose any items that you think should have been included in this list.†

Nursing Care and Management

Description
The module should handle all the processes involved in the daily transactions that occur in a ward, these transactions involve test requisitions placed for the patient, medicines consumed by the patient, bedside procedures performed, medical equipment connected to the patient , and recording of all visits by the doctor.
Furthermore, the nursing module should allow for the capturing of nursing assessment data, nursing plans and checklists, nursing charting/progress notes, nurse management / rostering and nursing quality assurance. All of these are essential as the patientís physical condition throughout the hospital stay needs to be recorded, nursing plans and checklists would help in the quality of care provided by nurses as well as the effective management of nursing resources throughout the hospital.
The application should enable managers and heads of all groups to create detailed, accurate, on-line work schedules for their staff. The required software should provide all information necessary to simplify staffing and scheduling.
Authorized schedule makers should be able to experiment with draft schedules on-line before creating a final schedule.


>>> General
1 Outpatient reservations inquiry
2 Inpatient vital signs monitoring
3 Inpatient medications monitoring
4 Inpatient requested investigations
5 Inpatient admission list viewing
6 Inpatient transfers lookup
7 Inpatient discharge nursing orders completion
8 Inpatient bed management:- View of bed board by facility, unit (ward ) , room
9 Inpatient bed management:- View beds that are currently occupied , reserved , or vacant
10 Inpatient bed management:- Display rooms by Occupancy
11 Inpatient bed management:- Display rooms by Gender
12 Inpatient bed management:- Produce Inpatient operations list
13 Inpatient bed management:- Produce Inpatient therapeutic procedures list

>>> Assessment Data
14 Support on-line entry , inquiry , and update of patient assessment data during patientís stay
15 Support multiple patient searches ( ex: name, ward and clinic searches)
16 Support patient's medical history viewing
17 Display patient alerts and allergies
18 Assessment data to include : a) height and weight b) blood pressure c) temperature and pulse d) urine and stool testing e) chest drainage f) medication data g) diet h) other items Ö.
19 Include patient demographic data from admission module into nursing assessment sheet
20 Include patient height and weight data on nursing assessment sheet
21 Include patient vital signs and allergy data on nursing assessment sheet
22 Include admission source on nursing assessment sheet
23 Provide flexibility for users to define assessment and care plan data requirements without programming
24 Support on-line assignment and update of acuity levels for patients
25 Automatically update acuity levels as treatments and procedures are entered
26 Maintain and allow on-line inquiry to acuity history for each patient
27 Provide on-line inquiry into acuity levels by nursing unit showing all patients on unit
28 Maintain acuity history data by date, shift, and care level
29 Allow for free text entry of the assessment data
30 View data in summary form ( ex: neurological , cardiovascular, etc.. )
31 Interface to external monitoring devices , i.e. telemetry units
32 Retrieve a patientís chart from a previous stay
33 Generate recommended and suggested nursing diagnoses based on assessment data
34 User Defined assessment screen
35 Allow assessment at various stages of the patientís stay ( ex: on admission , every 24 hours, on discharge )

>>> Nursing Plans and Checklists
36 Provide reminders, checklists and planning documents
37 Draw a standard care plan from the diagnosis retrieved from the Doctorís assessment data
38 Define multidisciplinary plans ( ex: therapists activities and drug dispensing integration )
39 Generate care plans based on historic data for particular diagnosis
40 User defined diagnosis or use standard diagnosis
41 Nursing Care Plan to include ex: risk factors, signs and symptoms, outcome criteria, nursing interventions and discharge criteria
42 Produce an automatic shift to shift summary of all information required by the new shift
43 Availability of checklists , i.e. actions required at change of shift , nursing round checklists, pre-op checklists
44 Ability to enter checklists into the system for different specialties ( ex: ER, OR , delivery,etc..)
45 Interact with Doctorís assessment to produce diagnosis , treatment and care plan , including expected outcomes , if required
46 Produce worklists for nurses of the activities to be performed at various times through the shift
47 Support I.V. worklists
48 Record actual nursing interventions and compare with a planned one
49 Ensure that all the necessary administrative arrangements are completed before discharge
50 Display a patient activity list including up to the minute status of all orders, activities, physician orders , visits and activities
51 Support automatic retrieval of standard care plan elements by diagnosis
52 Support automatic retrieval of standard care plan elements by patient classification
53 Support automatic retrieval of standard care plan elements by DRG
54 Allow editing of standard care plan text for tailoring to patient specific needs
55 Allow free text entry ( from scratch) of non-standard care plans
56 Allow for Guest request for meals and beds , and generate charges

>>> Nursing Charting / Progress Notes
57 Capture nursing progress notes and observations
58 Code notes using devices such as canned phrases
59 Record pharmacy interventions and dispensing as they take place
60 Log id, time, and date of staff entering, reviewing, performing, and discontinuing care plans
61 Support on-line charting of nursing care results and patient conditions
62 Track expected and actual time required to achieve nursing goals for patients
63 Support on-line charting and display of nursing and physician progress notes on demand
64 Facilitate entry of all Medical equipment, which has been connected to the patient

>>> Nurse Management
65 Record nursing employee data , i.e. personal data, education, appointment data, allocation records ..
66 Match available nursing resources to patient requirements
67 Handle nurse scheduling
68 Hold times for all interventions
69 Ability to translate times to whole-time-equivalents ( WTE ) and matched to personnel information
70 Ability to calculate indirect/non-bedside nursing time by comparing actual hours available with timed interventions
71 Ability to handle acuity/dependency that is not based on a nursing intervention

>>> Nursing Care Quality Assurance
72 Evaluate nursing standards and procedures to provide quality care
73 Produce questionnaires from the system
74 Assess nursing as well as administrative functions
75 Support Continuing education plans and contributions
76 Ability to enter questionnaires, once completed by nurses, for analysis
77 Generate random questions for the questionnaire
78 Availability of checklists on the system ( i.e. actions required at change of shift, nursing round checklists, pre-op checklists)
79 Questionnaires be designed by the nursing management or are standard ones available
80 Ability to split these questionnaires into different categories and/or specialized areas
81 Questions be amended ( i.e. added, deleted or amended, as necessary for different shifts )
82 Ability to print questionnaires
83 Provide analysis printouts to assess the performance of nursing staff over a particular period
84 Produce weekly and monthly analysis print outs
85 Maintain hospital-defined standard instruction text for developing patient instructions
86 Allow editing of standard instruction text for tailoring to patient specific needs
87 Print pre-surgical checklists for patients on demand
88 Provide on-line display of all instructions given to patient during stay
89 Support on-line catalog to hospital pamphlets, videos, and other patient education material
90 Maintain hospital defined standard discharge plans for developing patient discharge plans
91 Allow editing of standard discharge plans for tailoring to patient specific needs
92 Store and retrieve hospital-defined discharge plans by diagnosis
93 Store and retrieve hospital defined discharge plans by medication
94 Store and retrieve hospital defined discharge plans by physicians

>>> Reports
95 Print hospital defined standard care plans on demand
96 Print admission, interim, and discharge assessment sheets on demand
97 Print active care plans by patient on demand
98 Print patient care summary including all admit, interim , and discharge assessments and care plans
99 Print management standards of care report

>>> Integration
100 Integrate with Inpatient Admissions, Transfers and Discharges
101 Medical Records coding
102 Order Result management
103 Personnel and Payroll


Last Updated ( Tuesday, 28 October 2008 01:42 )  

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