Medical Blog

THE STUDY GUIDE ON COMPUTERIZATION OF UNITS CARE [4]

The patient record


All the activity of the ward is organized around the patient. The record is really the point central information system.

This folder is a player in the unit of care in terms of the motivations of its approach and needs of its task within the organization.
Each actor will be concerned by reports that patient records will make for him appropriate representation of reality.
The profusion of adjectives used about the patient's chart reflects the difficulty to identify consensus on that concept. These include:

• File lifetime
• the hospital records,
• the summary document,
• File specialty
• the case of emergency
• folder shared,
• folder unique biological,
• the clinical record,
• file transmission
• the common file,
• Minimum file
• The archival record.

The concepts of medical and nursing records are examples encountered in practice.
The roles of an actor vis-à-vis the patient record information can be varied:
• creator of information and therefore primarily responsible for the quality of information,
• user information.

Communication with medico-technical services

The adoption of new farming methods in the care units, to be successful, must contribute to simplify communication between partners.
The medico-technical account, by the nature and volume of their trade with the units
care, type of partner the most important of these.
Communication with the medico-technical services was identified as the second pole of the computerization care units.

Care planning

Care planning is the third pole of the computerization of patient care units.
It is situated midway between the first two poles because it must be understood as the articulation between two additional concerns:

• forecasting of nursing actions, which takes into account the elements of the patient record, such as: prescription, the prescription of nursing actions,
• the performance of nursing actions, which makes communication with stake medico-technical services.

This joint should be visible from two distinct angles:

• care plan for each patient,
• workplan for the team.

The diagram below shows the location of poles and priorities in relation to all functions of the nursing unit
4.7 Integration in the HFD and solution architecture.
The computerized care unit is a subset of the information system of the hospital (EIS) and should fit better in this system. For this, it must be open to trade with other sub-systems.
The example of a comprehensive computerization, integrating all the services of a hospital, is rare because of the need to mobilize within a relatively short (3-4 years) a set of means significant financial and human.
The reality tends to computerization decentralized services, interconnected systems administrative and medical techniques on the same communication network. It is possible, to some extent, harmonize heterogeneous information by connecting a communication system.

This system concept includes a dual concept:

• substantive concept of communication network,
• logical notion of exchange standards and presentation.

5. CONCLUSION

This overview on the objectives and strategy for the computerization of health units covers only part of the document produced by a group of professionals and society SETEC Computers under the leadership of Branch Hospitals.
The three priority clusters: the patient record, communication with medical technology and services care planning, will be the subject of detailed studies in the coming months. Our desire is to reach at Following these studies, the achievement of one or more specifications for the computerization of units care.
The positive reception by the hospital computer and commissions of several learned societies the standard specifications of laboratory management, the recent completion of an identical document desired radiologists on the computerization of radiology services, encourage us to continue in this direction Our thoughts and achievements.