12:26 PM
maestr0
The "user folder" multiprofessional, unique as a tool for sharing and comparing the various health professionals, it is frequently the subject of interest, especially at the administrative level, but clashes with the complexity of the "coexistence" of the data.
Not only the extent of nursing focus is so broad as to make it difficult to document the same synthesis, but the medical and nursing records, even if aimed both at the same goal, the following theories, methods and strategies are very different, which can also intersect and interact, but which can not coexist in the documentation.
The only instrument that has no contraindications of cohabitation, which could and should interact with all health professionals, is the diary. It should unite the nurses and the doctor, merging to create a "diary user" unique, open to the entire health care team.
Whether it be a piece of paper or a screen software, is the most simple and powerful interactive multi-document. It must be emphasized that, although stored in a different place during use, the folder is still nursing to be considered an integral part of the medical record , as complete documentation of the user / client, and will reunited with the filing, by the nursing coordinator / charge nurse, responsible for archiving documents.
