Autors:( António(Páscoa FámaIsidoro(...program (only for the project managers) • This training...
Transcript of Autors:( António(Páscoa FámaIsidoro(...program (only for the project managers) • This training...
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Autors: António Páscoa Fá1ma Isidoro
Beja, PORTUGAL
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The computerized records in nursing:
• Making clinical decisions, • Continuity and quality of care, • Management, • Training, • Research, • Decision-making processes, • Legal and ethical imperative that
involves them.
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Portugal -‐ Southwestern Europe -‐ Iberian Peninsula
Beja -‐ Alentejo region. - Total population of 35000 inhabitants.
Our Hospital -‐ 230 beds -‐ 5 Opera1on Rooms -‐ PACO with 6 beds
Where is José Joaquim Fernandes Hospital?
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The Opera1on Room
• Physical imbalance • Serious illness • Severe trauma • Must be solved with
an aggressive and invasive technique
A surgery is a unique experience for each individual, which lives it according to their own values and beliefs.
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Data collection • Data are used, not only to achieve a
complete nursing record of the patient’s condition and reactions, but it also should offer the guidelines to the nurse who provides care
• When accurate and reliable records are available, nurses have in his possession an instrument able to assess the evolution of the patient.
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How our informatics support has been structured, developed and implemented in the perioperative nursing environment, in the José Joaquim Fernandes´s
Hospital Operation Room in Beja – Portugal.
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Our plan:
- Choosing the right software.
- Learn how to deal with the program as a user.
- Obtain training to customize de program.
- Customize both medical and nursing parameters.
- Building layouts.
- Human resources training in Metavision.
- Go-live.
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Choosing the right software
• Collects data from bedside devices and hospital information systems.
• Record every detail of diagnoses and treatment plans.
• Support specific workflows and practice patterns
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Learn how to deal with the program as a user and obtain training to
customize de program.
• 12 hours training to became a super-user. • 32 hours training to learn how to customize the
program (only for the project managers) • This training was carried out by iMDSoft.
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Customize both medical and nursing parameters.
"Nursing, as a science and a profession that deals directly with human beings, needs in this stage, to assist the patient in all their complexity and need, for both objective and complex records about that patient."
JORGETTO (2005)
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"the duty of conveying information about the care provided to patients, is inherent in professional roles assumed by nurses. "
DEODATO (2009)
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Customize both medical and nursing parameters.
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"Records turn communication easier among team members and promotes the continuity of health care, reflects the care plan and can be used as a legal record of provided health care. "
CUNHA (2007)
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Customize both medical and nursing parameters.
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• Parameterization of : – the drugs, – units of measurement, – and the medical devices that are used in clinical
care. – The database was customized to local OR and PACO needs.
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Customize both medical and nursing parameters.
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• Nursing Interventions Classification (NIC), • The guidelines of the AESOP (Portuguese
association of perioperative nurses) • The guidelines of EORNA (European
operation room nursing association). • International Classification for Nursing
Practice • Nursing Minimum Data Set
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Customize both medical and nursing parameters.
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Building layouts.
Our goal in developing this organization was settled in a important rule:
KISS
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K eep I t S imple and S tupid
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We created several layouts.
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...secondary bars
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... and several forms
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…that allow to register with detail the nursing interventions.
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Human resources training in Metavision
• Ordinary users -‐ 12 hours standart training.
• Super-‐users -‐ 12 hours standart training and 6 hours of individual teaching and exercise training
• This training was carried out by Fatima and me, the project Managers.
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In every shi[ was scheduled one super-‐user to suport the rest of the team to perform the basic tasks
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Go-Live
• Go-‐live was performed on May, the 1st.
• Documenta1on was switched to computerized char1ng.
• Papperless and with no double char1ng.
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Vasco da Gama Bridge -‐ Lisbon, Portugal 23