Folder Nursing

The folder is a nurse on paper and / or computer system, which contains the recording of data and all documents pertaining to nursing on the case / user. Certifies and logically organized and effectively all the information and assistance activities of the person, collected and / or performed by ' nurses , fostering empowerment. It is used for writing history , for the definition of charitable objectives, for the annotation of the interventions and evaluation of results. The core of the folder is the nursing care plan customized. Formally recognized by art. 69 of DPR 384/90, is legally considered a public document, compiled by a person appointed as a public service. While not possess the same probative force, for greater completeness of health records to be stored as part of the medical record .

Premises

The 90s saw a proliferation of "nursing folders" with many different features. Initially placed all their attention to data collection, interviews with medical history, pre-compiled modules to be ticked and rating scales, but failed almost completely nullified the plan of care and, therefore, their main purpose. The folder is currently nursing a mature tool, which fully meets the criteria of effectiveness and efficiency required by companies, but arises from the need to fill a cultural void in those situations where no provision is made ​​for medical "problem oriented" (with annotations of different professionals in order, subject to individual user problems, communicating and interacting with each other). The recordings are therefore mainly "aimed at the source" (eg on printed forms with separate sections, reserved for professionals of different interventions, parallel to each other but not interacting). In addition to this, each operating reality then the document needs specific intensive care nurses, for example, have a need for additional documentation very different from that of a psychiatry nurses. After these premises, it is evident that you may encounter difficulties in conceiving and implementing a nursing business directory.