Care documentation
From NursingWiki
United States
In the United States, the federal Medicare insurance system pays for in-home care. Services include direct care visits by registered nurses, therapists (physical therapists, speech therapists, occupational therapists), social workers, nurse aides, and sometimes other providers such as dieticians. Care is provided according to a Care Plan which is authorized by a physician. Care delivery is documented. Each home health agency may use its own documentation forms. In recent years, software vendors in the United States and in Canada have created applications that replace paper documentation forms. Home health providers are equipped with laptops, tablet PCs, PDAs, and other portable devices. Data to document a patient's progress as outlined in the care plan is entered into one of these devices. The device is then synchronized to the facilities information system server and information becomes part of the electronic medical record.
United Kingdom
In the United Kingdom "the care plan", prescribing nursing care, following assessment of the Patient/client's needs, is made by a registered nurse, without recourse to medical staff. Whilst there is concern that the seperation of the nursing assessments over a number of individualised care plans has lead to the de-skilling of the nurse in terms of their assessment capabilities, there is another argument used that the nurses on the wards are made freer to assess the more physical attributes of care on admission - is the patient in pain, does the x-ray look acceptable; and also that the nurse on the ward needs to have less social information and more physical information due to the ever-shortening length of stay in the UK health system. This is contested - some nurses claim that the social information that is lost is extremely important as it is a core of nursing; others argue that this is not the case, and it remains to be seen which will win out.
The NHS in particular, one of the world's largest employers with 1.2m people, is beginning to introduce a global electronic patient record system, with information on all 62m patients that it serves. This project is extremely expensive and is currently going badly wrong (mid-2006), but it is hoped that it will ease the burdens involved in the administration of patient records in the NHS considerably, but will already hold all social and pertinent patient information on it, and therefore it becomes more important to assess the patient physically the socially; this will have already been done.
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