Expediente Clinico-kardex y Notas de Enfermeria

EXPEDIENTE CLINICO LA HISTORIA HISTORIA CLÍNICA DE LOS ESTABLECIMIENTOS DEL SECTOR Norma Téc Técnic nica, a, Nº 022 022-MIN -MINSA/DG SA/DGSP-V SP-V.02 .02

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Historia Clínica:

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IMPORTANCIA: 

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Documento médico legal Medio para comprobar la calidad de atención que los pacientes an rec o. Fuente de información con fines

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NORMAS REDACCIÓN REGISTROS: 

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Objetiva: debe tener información descriptiva y objeti objetiva, va, sobr sobre lo lo qu quee se se ve, ve, oye, siente siente y huele. huele. Exacta: La inform informaci acion on debe debe ser verdad erdadera era.. No uti izar a re reviaturas no apro a as as, pue e ar lugar a interpretación erroneas. Completa: Cuando los registros son

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NORMAS REDACCIÓN REGISTROS: 

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Concisa: Los registros deben ser breves, evitar palaras innecesarias. Actualizada: Los datos deben informarse en el momento preciso de observarse. Ejm la variación de los signos vitales. Organización. Es importante informar en siguiendo un formato o orden lógico.

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ESTRUCTURA DE LA HISTORIA HIST ORIA CLÍNIC CLÍNICA: A: 1.- Identif tifica icación ión del pacie ciente (datos personales del paciente y no de la historia clínica) 2.- Registro de la Atención de Salud (se tenido el paciente en el cual el personal de salud correspondiente la registra en el formato que le de gú la ción ción ibid ib id Ej La

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FORMATOS DE LA HISTORIA CLÍNIC CLÍ NICA A HOSP HOSPIT ITALI ALIZA ZACIÓ CIÓN N

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1.--HOJA 1. -HOJ HOJA A DE AUT AUTORIZ ORIZA ACIÓ CIÓN N DE INGRESO 

Datos de identificación identificación del paciente, Datos de identificación identificación de la persona persona legalmente responsable responsable que solicita el ingreso ingreso.. Firma

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3.-- AN 3. ANAM ANAMNESIS AMN NES ESIS IS  

Fecha y hora de la atención. Enfermedad actual: relato de la enfermedad, funciones biológicas

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5.-- DI 5. DIA DIAGNÓSTICO AGN GNÓS ÓST TIC ICO O 

Diagnóstico(s) presuntivo(s) o Diagnóstico(s) definitivo(s) del paciente en el momento de la admisión. Nombres y apellidos,

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7.-- PL 7. PLA PLAN AN DE TR TRA TRABAJO ABAJO 

Exáámene Ex meness auxilia iliarres, Prueb ruebas as espe speciale iales, s,

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Procedimiento:

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La enf enferme ermera ra qu quee admi admite te al paci pacien ente te conf confec ecci cioona la tarjeta de kardex. Debe incluir las necesidades y/o problemas del paciente para de esta manera, sea manejado por todo el equipo de salud que interviene en el cuidado del mismo. Especificará las medidas tomadas por la (él) enfermera (o) no ordenadas por el médico, pero que creyó su deber hacerlo para que satisfaga una necesidad específica a través del Plan de cuidado Registrará las acciones de enfermería para el paciente planificad planificadss de acuerdo acuerdo a las prioridade prioridadess determinad determinadas as en el Dia Diagno nost stic icoo de enfer nferm mería ería y las las coo oorrdinac inacio ione ness

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Procedimiento: 

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Se debe incluir las acciones de enfermería basadas en principios cientificos y deben tener eficacia. Medi Medida dass tera terapé péut utic icas as orde ordena nada dass po porr el médi médico co y aplicadas por el personal de enfermería. Debe incluir la mayor cantidad de necesidades y/o problemas del paciente parta poder ser manejado conveniente. El plan de cuidados reflejados reflejados en el kardex kardex tendrá en cuenta las necesidades psicosociales del paciente y la interrelación de estas necesidades con las

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FORMATO DE KARDEX DE ENFERMERIA 

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NOMBRE NOMBR E PACIENTE: PACIENTE: EDAD: DIAGNOSTICO MÉDICO

TRATAMIENTO MEDICO

FRECUENCIA

FECHA Y HORA

FECHA Y HORA

OBSERVACION ES

TRATAMIENTO DE ENFERMERIA

FRECUENCIA

FECHA Y HORA

FECHA Y HORA

OBSERVACIONES

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