THE CARE FILE - SYNTHESIS OF THE QUALITY AND SAFETY OF NURSING CARE - - PowerPoint PPT Presentation
THE CARE FILE - SYNTHESIS OF THE QUALITY AND SAFETY OF NURSING CARE Assoc .Pr of .Ile ana ANT OHE , Cr istina CHIRIAC-RN, PhD MD, PhD He ad Nurse Popa Ia i Univ ,,Gr T Clinic al E me rge nc y Hospital ,,Sf Spiridon Ia
Assoc .Pr
OHE , MD, PhD Univ ,,Gr T Popa’’ Iași
Clinic al E me rge nc y Hospital ,,Sf Spiridon’’ Iași
Cr istina CHIRIAC-RN, PhD
He ad Nurse Clinic al E me rge nc y Hospital ,,Sf Spiridon’’ Iași
He a lth se r vic e s e va lua tor ANMCS
Or ganize d pr
Dynamic pr
ste p c an add ne w patie nt data Cyc lic – inte r r e late d ste ps Me thod of planning and pr
Individualise d inte r ve ntions Sc ie ntific me thod to solve ac uat or pote ntial patie nt’s pr
Applie d pr
thr
nur sing plan
1
NT RAL ISE D GE NE RAL DAT A- ADDMISSION PARAME T E RS 2
ORME D CONSE NT
3
ORMAT ION ON HOSPIT AL RUL E S 4
HE NURSING PL AN 5
VAL UAT ION OF F AL L RISK– DOWNT ON SCAL E 6
VAL UAT ION OF PRE SSURE UL CE RS RISK- NORT ON SCAL E 7
NT OF PAT IE NT ’S MOBIL L IT Y 8
ORING PE RIPHE RAL VE NOUS CAT HE T E R (PVC) 9
XPE CT E D PROBL E MS DURING HOSPIT AL ADDMIT T E NCE
10
IVIT IE S
11
AL T H PROMOT ION E DUCAT ION
12
NT ON DE L IVE RE D CARE AND RE COMME NDAT IONS ON DISCHARGE
1
2
3
4
T HE RE GIST E RE D NURSE
F unda me nta l pa tie nt’s ne e ds
Nur sing diagnostic s
Indic a tor s for e ffic ie nc y of c a r e file L imit/ a ddmite d inte r va l Structure indicators
Process indicators
Nr of care plan with nursing objectives in agreement with therapeutic conduct/Total Nr total verified care plans Ratio = 1. Whole staff should have 8/10 in the assessment of the procedure related to the use of care plan Ratiot = 1. All patient files should have care plans Ratio = 1. All care plans should be complete
Result indicators
Nr of patients and family’ complaints related to the received care /Total Nr. Of inpatients
Nr of pressure ulcers developed during hospital stayTotal nr of inpatients
INDICAT ORS OF E VAL UAT ION AND MONIT ORING OF E F F ICIE NCY OF CARE file
M a n a g e m e n t u l
CR 020305
ME DICAL DAT A ARE RE GIST E RE D COMPL E T E L Y, CORRE CT AND IN RE AL T IME WIT HOUT RE DUNDANCE
CR 020304 CARE PL AN IS PART OF CASE MANAGE ME NT CR020303 T HE HOSPIT AL E NSURE S CONT INUIT Y OF CARE AF T E R INIT IAL E VAL UAT ION CR 020302 INT E GRAT E D APPROACH T O CARE IS CURRE NT PRACT ICE CR 020301
CASE MANAGE ME NT USE S DE DIAGNOST IC AND T HE RAPY PROCE DURE S
02.03.04 Cr CARE PL AN IS PART OF CASE MANAGE ME NT 02.03.04.01 C Staff ensures complete and personalized care of the patient 02.03.04.02 C Nurses elaborate the care plan according to the medical problems 02.03.04.03 C The care plan is adapted in correlation to patient’s evolution 02.03.04.04 C On discharge the care plan is transmitted to the patient, the family, the GP or the physician who sent the patient for addmittence 2.03.04.05 C The necessary number of stff is established in accordence with the needs of the patients
Re sponsible attitude
ds the patie nt Staff c ompe te nc ie s ar e ac c or ding to the patie nt’s c ar e ne e ds Staff numbe r is ade quate to the patie nts’ c ar e ne e ds
T he de sign of the c ar e plan for the involve d spe c iality
Nur se e duc ation towar ds the use and imple me ntation of the c ar e plan
Ide ntific ation of me dic al r isks r e late d to the patie nt’s c ar e
ifie s the c onc or danc e in r e al time be twe e n me dic al pr e sc r iptions, hygie nic and die tar y r e c omme ndations and the c ar e plan
iodic ally analyse s the c onte nt of c ar e plans e labor ate d by nur se s and e nsur e s that e r r
s ar e not r e pe ate d
he atte nding physic ian:
ge doc ume nts c ontain the c ar e plan and e nsur e s the c ontinuity of c ar e
ge doc ume nts c ontain the c ar e plan and e nsur e s the c ontinuity of c ar e
T he he ad nur se
Adapts the staff number to the care needs Establishes the number of staff depending
dependence Ensures the staffing according to the assessment of patients’ needs