Evolution of Nursing Documentation in the Surgical Process: “A forward looking”

摘要

Introduction : The Alto Deba Hospital has been offering surgical services since 1965. Since then, many changes have taken place in our Organization. These changes have led to a clear improvement in people-centred care. In this context, the surgical process represents another link in the integration care. Therefore, the registration of nursing care in each of its phases is of the utmost importance in order to achieve less fragmented, more coordinated, more efficient and higher quality health care. Short description of practice change implemented : The information related to the Nursing Care Plan in the surgical process was fragmented between the different welfare levels that were part of the same one. The implementation of a new nursing registration model has made it possible for the different actors involved in the surgical process to have all the necessary information at their disposal from any point in the process. Aim and theory of change : Integrated care is a principle of the health care organization that seeks to improve health outcomes for patients through the integration of health care processes, in order to provide coherence and take advantage of synergies between the different levels of the health care system. The main objective of this project has been to integrate the Nursing Care Plan into the surgical process and improve its scope, moving from fragmented model to a unified and integrated model, eliminating the existing barriers between the different levels of care. Targeted population and stakeholders : Targeted population: A person who will be operated an as a result will require a Nursing Care Plan from admission to discharge at home. Stakeholders: - Operating rooms - Post anesthesia resuscitation unit (URPA) - Surgery Department - Primary care - Outpatient Consultations Timeline : 2014-2018 Highlights (innovation, impact and outcomes) : All patient information about the surgical process and nursing care performed is integrated and coordinated in a single application. Comments on sustainability : A single application (Osanaia), acts as a transmitting element and link for the different levels of care, providing coverage for all the nursing records that take place during the surgical process: Surgical Area, Hospitalization and Primary Care. Comments on transferability : The use of this tool and its implementation from the surgical process, has been a clear element of improving the skills and abilities for the nursing profession. Conclusions : Looking back, we see that over the years, technology has advanced by leaps and bounds but the nursing care record is aligned with this growth. Discussions : The work is not finished and we have pending challenges, to involve other actors of the surgical process in this project: emergency department, delivery service among others. We all have to have the capacity to see everyone from their profession but all from one point of view: the patient. Are we ready? Lessons learned : In health matters, anything is possible. Teamwork, shared knowledge and constant improvement are key elements in generating a culture of integrated care. Let’s keep moving forward.