Chief Nurse Documentation
All documentation of the head nurse consists of several large sections.
I. Regulatory framework.
II. Branch passport.
III. Pharmacy documentation.
IV. Materials on the activities of nursing staff in the department.
V. Folders and magazines on various aspects of the work of a senior nurse.
Let's take a look at the sections in more detail.
I. Documentation of the head nurse on the regulatory framework
- Job descriptions for all categories of middle and junior medical personnel working in the department.
- Orders of the Ministry of Health of the Russian Federation, the USSR, the regional Ministry of Health, local higher organizations regulating the activities of paramedical personnel.
II. Passport of the department or structural unit of the head nurse
- Characteristics of the department (area, set of rooms, profile manipulations).
- Collective agreement.
- Bed fund of the department for a year.
- Staff schedule.
- Vacation schedule for employees and understudy.
- Schedule of periodic medical examinations.
- The plan of conversation with new entrants to work.
- Department work plan.
- The work plan of the senior nurse for the year by section.
- The work schedule of the senior nurse on the days of the week.
- Activity report for the past year.
- Plan for advanced training.
- Plan of work with the reserve of the head nurse.
- The plan for attestation and certification of the regional and city attestation commissions, days and hours of acceptance of attestation works.
- Plan of work with young specialists.
- List of department instructors.
- Lesson plan with junior medical staff.
III. Pharmaceutical order:
- Medicinal formulary.
- List of thermolabile preparations.
- List-permission to work with the National Assembly and PV employees of the department, order for health facilities.
- List of higher and single doses of NA and PV, potent, poisons.
- Magazines:
- Accounting for narcotic and psychotropic substances
- Accounting for poisonous and potent drugs
- Alcohol accounting
- Accounting for dressings
- Accounting for returned used ampoules and blisters from under the NA and PV (at the main one, if you accept)
- Acts on the destruction of used ampoules and blisters from under the NA and PV.
IV. Information about the activities of nursing staff
- List of employees of the department, indicating their age, date of birth, home address, educational institution they graduated from, place and time of advanced training, availability of attestation experience, category, certificate, office and home (mobile) phone.
- Medico-technological protocols for nursing manipulations, or standards for the activities of nurses, permitted in practical work by order of the head physician of the health facility, algorithms for the actions of a nurse in emergency conditions.
V. Folders and journals of the head nurse
Folders:
- Instructions for the use of disinfectants, certificates of quality and conformity.
- Safety Instructions.
- Orders for medical facilities by profiles.
- Classes on civil defense and emergencies. An order with a list of responsible persons, etc., according to the scheme of action.
- Actions of personnel in case of detection of AGI with the tactics of managing patients.
- Plan and results of production control.
- Educational and methodological material for working with students of medical academies, colleges, schools of the region and other regions.
Magazines:
- Accounting for the use of working time.
- Stationary journal (registration of patients).
- Passage of medical examinations by employees of the department.
- Briefing on labor protection, safety and fire safety.
- Health journal according to orders Nos. 345, 330.
- Accounting for the presence of complications in patients received through the fault of paramedical workers (GSI, VBI).
For the head nurse, by analogy with the list of the head nurse, and add:
- Plan of the Council of Sisters, taking minutes of meetings.
- Regulations on the Council of Sisters.
- Plan of conferences for paramedical workers, keeping minutes of conferences.
- Regulations on the attestation commission (if you have one).
- Minutes of the meetings of certification of paramedical workers.
The head nurse's documentation may be more extensive than the list above. You can also add everything that you maintain and work with.
medical and technological protocols for nursing manipulations, standards for the activities of nurses, permitted in practical work by order of the chief physician of a medical organization, algorithms for the actions of a nurse in various emergency conditions.