| | Description | The module should handle all the processes involved in the daily transactions that occur in a ward, these transactions involve test requisitions placed for the patient, medicines consumed by the patient, bedside procedures performed, medical equipment connected to the patient , and recording of all visits by the doctor. Furthermore, the nursing module should allow for the capturing of nursing assessment data, nursing plans and checklists, nursing charting/progress notes, nurse management / rostering and nursing quality assurance. All of these are essential as the patient’s physical condition throughout the hospital stay needs to be recorded, nursing plans and checklists would help in the quality of care provided by nurses as well as the effective management of nursing resources throughout the hospital. The application should enable managers and heads of all groups to create detailed, accurate, on-line work schedules for their staff. The required software should provide all information necessary to simplify staffing and scheduling. Authorized schedule makers should be able to experiment with draft schedules on-line before creating a final schedule. |
| 1 | | Outpatient reservations inquiry | | 2 | | Inpatient vital signs monitoring | | 3 | | Inpatient medications monitoring | | 4 | | Inpatient requested investigations | | 5 | | Inpatient admission list viewing | | 6 | | Inpatient transfers lookup | | 7 | | Inpatient discharge nursing orders completion | | 8 | | Inpatient bed management:- View of bed board by facility, unit (ward ) , room | | 9 | | Inpatient bed management:- View beds that are currently occupied , reserved , or vacant | | 10 | | Inpatient bed management:- Display rooms by Occupancy | | 11 | | Inpatient bed management:- Display rooms by Gender | | 12 | | Inpatient bed management:- Produce Inpatient operations list | | 13 | | Inpatient bed management:- Produce Inpatient therapeutic procedures list | | 14 | | Support on-line entry , inquiry , and update of patient assessment data during patient’s stay | | 15 | | Support multiple patient searches ( ex: name, ward and clinic searches) | | 16 | | Support patient's medical history viewing | | 17 | | Display patient alerts and allergies | | 18 | | Assessment data to include : a) height and weight b) blood pressure c) temperature and pulse d) urine and stool testing e) chest drainage f) medication data g) diet h) other items …. | | 19 | | Include patient demographic data from admission module into nursing assessment sheet | | 20 | | Include patient height and weight data on nursing assessment sheet | | 21 | | Include patient vital signs and allergy data on nursing assessment sheet | | 22 | | Include admission source on nursing assessment sheet | | 23 | | Provide flexibility for users to define assessment and care plan data requirements without programming | | 24 | | Support on-line assignment and update of acuity levels for patients | | 25 | | Automatically update acuity levels as treatments and procedures are entered | | 26 | | Maintain and allow on-line inquiry to acuity history for each patient | | 27 | | Provide on-line inquiry into acuity levels by nursing unit showing all patients on unit | | 28 | | Maintain acuity history data by date, shift, and care level | | 29 | | Allow for free text entry of the assessment data | | 30 | | View data in summary form ( ex: neurological , cardiovascular, etc.. ) | | 31 | | Interface to external monitoring devices , i.e. telemetry units | | 32 | | Retrieve a patient’s chart from a previous stay | | 33 | | Generate recommended and suggested nursing diagnoses based on assessment data | | 34 | | User Defined assessment screen | | 35 | | Allow assessment at various stages of the patient’s stay ( ex: on admission , every 24 hours, on discharge ) | | >>> Nursing Plans and Checklists | | | | 36 | | Provide reminders, checklists and planning documents | | 37 | | Draw a standard care plan from the diagnosis retrieved from the Doctor’s assessment data | | 38 | | Define multidisciplinary plans ( ex: therapists activities and drug dispensing integration ) | | 39 | | Generate care plans based on historic data for particular diagnosis | | 40 | | User defined diagnosis or use standard diagnosis | | 41 | | Nursing Care Plan to include ex: risk factors, signs and symptoms, outcome criteria, nursing interventions and discharge criteria | | 42 | | Produce an automatic shift to shift summary of all information required by the new shift | | 43 | | Availability of checklists , i.e. actions required at change of shift , nursing round checklists, pre-op checklists | | 44 | | Ability to enter checklists into the system for different specialties ( ex: ER, OR , delivery,etc..) | | 45 | | Interact with Doctor’s assessment to produce diagnosis , treatment and care plan , including expected outcomes , if required | | 46 | | Produce worklists for nurses of the activities to be performed at various times through the shift | | 47 | | Support I.V. worklists | | 48 | | Record actual nursing interventions and compare with a planned one | | 49 | | Ensure that all the necessary administrative arrangements are completed before discharge | | 50 | | Display a patient activity list including up to the minute status of all orders, activities, physician orders , visits and activities | | 51 | | Support automatic retrieval of standard care plan elements by diagnosis | | 52 | | Support automatic retrieval of standard care plan elements by patient classification | | 53 | | Support automatic retrieval of standard care plan elements by DRG | | 54 | | Allow editing of standard care plan text for tailoring to patient specific needs | | 55 | | Allow free text entry ( from scratch) of non-standard care plans | | 56 | | Allow for Guest request for meals and beds , and generate charges | | >>> Nursing Charting / Progress Notes | | | | 57 | | Capture nursing progress notes and observations | | 58 | | Code notes using devices such as canned phrases | | 59 | | Record pharmacy interventions and dispensing as they take place | | 60 | | Log id, time, and date of staff entering, reviewing, performing, and discontinuing care plans | | 61 | | Support on-line charting of nursing care results and patient conditions | | 62 | | Track expected and actual time required to achieve nursing goals for patients | | 63 | | Support on-line charting and display of nursing and physician progress notes on demand | | 64 | | Facilitate entry of all Medical equipment, which has been connected to the patient | | 65 | | Record nursing employee data , i.e. personal data, education, appointment data, allocation records .. | | 66 | | Match available nursing resources to patient requirements | | 67 | | Handle nurse scheduling | | 68 | | Hold times for all interventions | | 69 | | Ability to translate times to whole-time-equivalents ( WTE ) and matched to personnel information | | 70 | | Ability to calculate indirect/non-bedside nursing time by comparing actual hours available with timed interventions | | 71 | | Ability to handle acuity/dependency that is not based on a nursing intervention | | >>> Nursing Care Quality Assurance | | | | 72 | | Evaluate nursing standards and procedures to provide quality care | | 73 | | Produce questionnaires from the system | | 74 | | Assess nursing as well as administrative functions | | 75 | | Support Continuing education plans and contributions | | 76 | | Ability to enter questionnaires, once completed by nurses, for analysis | | 77 | | Generate random questions for the questionnaire | | 78 | | Availability of checklists on the system ( i.e. actions required at change of shift, nursing round checklists, pre-op checklists) | | 79 | | Questionnaires be designed by the nursing management or are standard ones available | | 80 | | Ability to split these questionnaires into different categories and/or specialized areas | | 81 | | Questions be amended ( i.e. added, deleted or amended, as necessary for different shifts ) | | 82 | | Ability to print questionnaires | | 83 | | Provide analysis printouts to assess the performance of nursing staff over a particular period | | 84 | | Produce weekly and monthly analysis print outs | | 85 | | Maintain hospital-defined standard instruction text for developing patient instructions | | 86 | | Allow editing of standard instruction text for tailoring to patient specific needs | | 87 | | Print pre-surgical checklists for patients on demand | | 88 | | Provide on-line display of all instructions given to patient during stay | | 89 | | Support on-line catalog to hospital pamphlets, videos, and other patient education material | | 90 | | Maintain hospital defined standard discharge plans for developing patient discharge plans | | 91 | | Allow editing of standard discharge plans for tailoring to patient specific needs | | 92 | | Store and retrieve hospital-defined discharge plans by diagnosis | | 93 | | Store and retrieve hospital defined discharge plans by medication | | 94 | | Store and retrieve hospital defined discharge plans by physicians | | 95 | | Print hospital defined standard care plans on demand | | 96 | | Print admission, interim, and discharge assessment sheets on demand | | 97 | | Print active care plans by patient on demand | | 98 | | Print patient care summary including all admit, interim , and discharge assessments and care plans | | 99 | | Print management standards of care report | | 100 | | Integrate with Inpatient Admissions, Transfers and Discharges | | 101 | | Medical Records coding | | 102 | | Order Result management | | 103 | | Personnel and Payroll | |