Care documentation

from Wikipedia, the free encyclopedia

The care documentation is the written fixation of the planned and performed care as well as the documentation of individual steps of the care planning . It is a central tool in professional nursing , elderly and children's nursing . The care documentation serves to ensure the next work steps of the caregivers and the cooperation in the care of the care recipients ( patients , clients , residents ) in the care team and with participating professional groups such as doctors. It includes all reports and forms about the care history of the respective person as part of a medical record , which can also be kept virtually as an electronic patient record . From a nursing point of view, your most important part is care planning.

The care documentation as a necessary tool

The individualized care documentation or documentation folder is a form of care documentation that brings together all written reports, tally sheets, plans and occasionally arising forms etc. about a person in a file about the care process of this person. It replaces previously used collection lists or handover books in which it is reported or enumerated alphabetically or chronologically what was done by nurses in a working group or what was reported about a person. This means that the information was spread over several places and was difficult to understand. From a nursing point of view, your most important part is nursing planning (nursing work preparation ). From an economic point of view, it is the proof of performance as the basis for billing with the respective cost unit. Overall, it prevents the loss of information, which could easily arise from a purely oral transfer between many people.

There are more or less complete form systems for different fields of work on the market. In addition to various index sheets or forms , folders and planettes, curve carriages or index troughs are required to summarize the documentation folders by area. The documentation can also be mapped paperless using data processing on the PC. The data can be entered using a keyboard , touchscreen or various scanner systems. This requires additional training in the respective software for all employees.

It is used every day for handovers , service meetings and the timely recording of all important activities. It is used daily / weekly for doctor visits and for reviews by the home supervisory authority , the medical service of the health insurance companies or for internal and external quality assurance procedures approximately annually. The daily time required for documentation is between five and fifteen minutes per person cared for.

When asked what needs to be documented and what information is not required, a motto by Reinhard Lay helps: "What is relevant in practice, remuneration, examination-relevant or legally required is fully, true and clearly documented."

According to the general understanding of the care professions, holistic care is much more than filled in forms. These are only intended to ensure that no essential information is lost.

Components of a care documentation

Master data ,
Care planning ,
Monitoring sheet (daily or weekly curves, lists , tables ),
Observations, report (freely worded),
medical prescriptions such as medication , prescribed diet ,
Notes , performance records and other things.

The documentation system is systematically divided into several parts in master data, care planning, medical treatments, monitoring sheet and in the freely formulated reports in the care or daily report and any additional sheets. Screening or care assessment are supplemented .

Frequently used additional sheets are: medical records / fever chart, medication prescriptions and administration, annual / monthly overviews (bowel movements, baths / showers, hairdresser, foot care, doctor visits, drainage and catheter changes , diet forms), administration of items and money brought along.

base data
(usually the top sheet, when viewed from above) Name, insurance company, cost bearer; Home address , relatives and their availability; legal supervisor or administrator , existing directives. Administrative features. This sheet contains a lot of unchangeable data, but also some that need to be supplemented or that lose their meaning over time. In this respect, this contradicts the designation master data.
Medical treatments
Names and contact details of the doctors, therapists or treatment centers involved in the care. Diagnoses, important previous illnesses (information from the medical anamnesis ), medication on admission, long-term medication, medication on demand (when, up to which daily dose); Delivery of the prescribed medication by pharmacies or similar; Emergency doctor visits and prescriptions ; Medical prescriptions to be observed constantly, when hospital stays; recurring illnesses with an emergency character and their initial treatment. BTM medication. Possibly. this information is also included in the curve, the tabular monitoring sheet.
maintenance
Habits, skills etc. according to ATL / AEDL ; Admission interview (see home admission ); previous care (summary report); Nursing history; Risk assessments (e.g. pressure ulcer risk on the Norton or Braden scale ); provisionally planned nursing care or nursing planning; Daily and weekly structure, participation in rehab and the like.
Care reports
They can be structured differently, e.g. B. like a diary or according to organizational areas of care. Evidence of performance can be structured according to cost figures or service packages.
Focused care reports
One type of care documentation from the Canadian area is the order according to different focuses. Each focus represents an acute problem for the patient. This nursing problem is documented by data (D). The carer then plans an action (A), which is also explained. This action should lead to a result (R) within 24 hours that corrects the patient's problem. If this is not possible, a care plan must be drawn up for this problem.

Electronic care documentation

For a long time there has been a discussion in specialist circles about how beneficial information and documentation technologies can be in care (process) documentation. In connection with the discussion of the benefits of electronic patient / resident files, the use of standardized care classifications is increasingly discussed and demanded.

In an overview, Schrader mentions the following classification systems for care documentation in an electronic patient / resident file in his publication:

Time savings through IT

A report by the Federal Statistical Office from 2013 showed that documentation with paper systems is fundamentally more time-saving than documentation on a computer. What is striking is the higher current value for electronic recording. The result reflects the experiences of some of the nursing homes questioned, where a fully electronic system was experienced as more time-consuming and therefore a return to a manual or partially electronic system was made. In inpatient care, IT documentation takes an average of 12.6 minutes per resident per day, compared to only 10.3 minutes with paper documentation.

In the outpatient area and in day care, an average of around 6 minutes per patient is needed with an EDP and 5 minutes with paper documentation.

Rules of use

The use of care documentation must be agreed in-house using rules. These should include, for example:

  • The current status should be found in the documentation.
  • Same abbreviations and symbols - uniformity between the stations. Documentation with abbreviations, symbols etc. is certainly permissible if the meaning of the abbreviations is stored in a forgery-proof manner and is still traceable even years later.
  • Abbreviated care documentation with reference to care standards is also considered permissible if the standards valid at the time of documentation remain traceable even after years (archiving).
  • The documentation should take place promptly (i.e. not only at the end of the work shift)
  • Changes required subsequently (e.g. after an error) must be marked as such.
  • What is not signed by name is deemed not to have been performed. Skilled workers' responsibilities for auxiliary workers.

Debureaucratisation

There is an ongoing debate about the necessary scope of care documentation. Many nurses and providers find the documentation too time-consuming and not very helpful in practice: “Nursing documentation and the complex nursing process planning are now very often processed with a view to the MDK examinations and home supervision. The practical relationship between nursing work and the aid 'nursing documentation' has therefore increasingly faded into the background in recent years ”.

In order to develop alternatives to current documentation systems, numerous initiatives and model projects have already been initiated, including in Hamburg, North Rhine-Westphalia, Bavaria and Schleswig-Holstein. The debureaucratised documentation system PFLEGE · ZEIT emerged from the Schleswig-Holstein model project.

Important results of these projects include the following approaches:

  • Transition to a four-step maintenance process,
  • Reduction of the complexity caused by care models ( AEDL / ATL ),
  • No documentation of individual services.

These elements can also be found in the recommendations on the basic structure of a de-bureaucratised care documentation from the ombudswoman for the de-bureaucratisation of care in the Federal Ministry of Health, Elisabeth Beikirch. These result from the project "Practical application of the structural model - increasing the efficiency of care documentation", the results of which were presented for the first time on February 19, 2014 in Berlin. According to these recommendations, the wishes of the person in need of care should determine the structure of care planning and documentation in the future. The detailed report on the project, in which around 60 care institutions and services tested model documentation, was published in April 2014. Since 2015 this has been continued under the “Ein-STEP” project.

literature

Books

  • V. Hielscher, L. Nock, S. Kirchen-Peters: Use of technology in elderly care. Potentials and problems from an empirical perspective . Nomos / edition sigma, 2015.
  • Birgitt Budnik: Care planning - made easy. 5th edition. With the collaboration of Reinhard Lay and Bernd Menzel. Urban & Fischer, Munich 2005, ISBN 3-437-26952-6 .
  • Friedhelm Henke: Care planning after the care process. individual-concise-practicable. 3. Edition. Kohlhammer Verlag, Stuttgart 2006, ISBN 3-17-019315-5 .
  • Reinhard Lay: Ethics in Nursing. A textbook for basic, advanced and advanced training. Schlütersche Verlagsgesellschaft, Hanover 2004, p. 157.
  • Ulrike Höhmann, Heidi Weinrich, Gudrun Gätschenberger: Uncovered and eradicated: Defects in documentation systems. "The importance of the nursing plan for quality assurance in nursing" - a project by the Agnes Karll Institute . 1997.
  • Petra Keitel: Action-oriented care documentation . Kohlhammer Verlag, Stuttgart 2007, ISBN 978-3-17-019302-4 .
  • Uwe Brucker, Gerdi Ziegler: Policy statement: maintenance process and documentation. Recommendations for action for professionalization and quality assurance in nursing. Self-published medical services of the umbrella organizations of the health insurance companies. V. (MDS), Essen 2005. (Download possible from MDS (approx. 800 kB, PDF))
  • Elke-Erika Rösen: Document correctly. Documentation in elderly care. Urban & Fischer Verlag, 2007, ISBN 978-3-437-27950-8 .
  • Susanne Graudenz: The nursing process in the nursing documentation of hospitals - presentation of an instrument for assessment and exemplary study. Diplomica Verlag , 2008, ISBN 978-3-8366-5837-9 .

Magazines

  • Angelika Abt-Zegelin, Hans Böhme, Peter Jacobs: "Patient inconspicuous" - Legal and nursing requirements for the documentation, part 1-3. In: The sister, the nurse . 2004.
  • Gabriele S. Herberger, Hindermann Anke: Requirements for the care documentation. Relief through process-oriented software. In: The sister - the nurse. 2004.
  • Petra Keitel: Nursing Documentation - Learning from Mistakes, Part 1–2. In: care outpatient. (2) 2007, p. 23.
  • Hans P. Wittig: Specifications for a care documentation. In: The old people's home. 31, 1992, pp. 156-162.

See also

Web links

Individual evidence

  1. ↑ Friedhelm Henke, Christian Horstmann: Nursing planning precisely corrected and formulated. Practical work aids for teachers and students. 2nd Edition. Kohlhammer, Stuttgart 2010, ISBN 978-3-17-021668-6 , p. 11.
  2. ↑ Reinhard Lay: Ethics in Care. A textbook for basic, advanced and advanced training. Schlütersche Verlagsgesellschaft, Hannover 2004, ISBN 3-89993-115-7 , p. 157.
  3. ^ V. Hielscher, L. Nock, S. Kirchen-Peters: Use of technology in geriatric care. Potentials and problems from an empirical perspective. Nomos / edition sigma, Baden-Baden 2015, pp. 45–86.
  4. ↑ E. Ammenwerth, R. Eichstädter et al.: EDP ​​in the care documentation. Schlütersche Verlagsgesellschaft, Hanover 2003.
  5. ↑ R. Trill: The computer in nursing: Basics, fields of application, introductory strategies. Schlütersche Verlagsgesellschaft, Hanover 1993.
  6. ^ RA Brobst, AMC Coughlin, D. Cunningham, JM Feldman, RG Hess Jr., JE Mason, LAF McBride, R. Perkins, CA Romano, JJ Warren, W. Wright: The nursing process in practice. Publisher Hans Huber, Bern 1997.
  7. ^ Ulrich Schrader: Nursing terminologies. In: K. Güttler, M. Schoska, S. Görres: Care documentation with IT systems, a symbiosis of science, technology and practice. 2010.
  8. ↑ P. Wieteck (Ed.): Practice guidelines care, planning and documentation based on care diagnoses of the ENP classification. RECOM Verlag, Kassel 2013.
  9. ^ NANDA International (2013). NANDA I Nursing Diagnoses Definitions and Classification 2012–2014. Kassel, RECOM Verlag
  10. ^ S. Moorhead, M. Johnson, M. Maas, E. Swanson (Eds.): Nursing Outcomes Classification (NOC): Measurement of Health Outcomes. 5th edition. Elsevier, St. Louis, MO 2013.
  11. ↑ GM Bulechek, HK Butcher et al: Nursing Interventions Classification (NIC). 6th edition. St. Louis, Missouri 2013.
  12. ↑ H. Stefan, F. Allmer et al.: POP PraxisOrientierte Pflegediagnostik Nursing diagnoses - goals - measures. 2nd Edition. Springer Verlag, Vienna 2013.
  13. ↑ a b Compliance costs in the area of ​​... care: application procedure for statutory benefits for people who are in need of care or who are chronically ill, project series Determination of the bureaucratic time expenditure and approaches to relief, Federal Statistical Office, Berlin March 2013, p. 116.
  14. ↑ Compliance costs in the area of… Nursing: Application procedure for statutory benefits for people who are in need of care or who are chronically ill, project series Determination of the bureaucratic time expenditure and approaches to relief, Federal Statistical Office, Berlin March 2013, p. 117.
  15. ↑ a b Michael Wipp: ( Page no longer available , search in web archives: final report. ) In: Project “Debureaucratisation of care documentation” on behalf of the Bavarian State Ministry for Labor and Social Affairs for Family and Women.@1@ 2Template: Toter Link / www.stmas-test.bayern.de
  16. ↑ Working group debureaucratised care documentation in the Hamburg-Eimsbüttel district: ( page no longer available , search in web archives: explanations and notes on the Hamburg model for reducing the bureaucracy of care documentation in inpatient care. ) Hamburg 2007.@1@ 2Template: Dead Link / www.hamburg.de
  17. ^ Ministry of Labor, Health and Social Affairs of the State of North Rhine-Westphalia - Closer to People (Ed.): Reference model 4 "Quality assurance and de-bureaucratization" . Results of the symposium “Quality assurance and reducing bureaucracy in nursing” on February 21, 2006 in Essen.
  18. ↑ Ministry of Labor, Social Affairs, Health and Consumer Protection of the State of Schleswig-Holstein: “We care really well!” Design of the care process from a care-related point of view. A handout, Kiel 2002.
  19. ↑ pflege-zeit.de
  20. ↑ pflege-zeit.de
  21. ↑ bmg.bund.de ( Memento of the original from May 8, 2014 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.bmg.bund.de
  22. ↑ einstep.de