Anamnesis

With careIT Pro you can use the integrated, interdisciplinary nursing history or easily insert individual histories. It forms one of the data bases for triggering the automated care process.

Assessment

careIT Pro comes standard with the nursing assessments for paediatrics, acute care, long-term care and psychiatry. Here we rely on the practice-proven assessment of the nursing scientists from ePA-CC. This provides you with a comprehensive assessment of your patient's self-care abilities and nursing-relevant risks within a few minutes. Messages to other departments (e.g. social services, wound manager or stoma expert) or nursing standards can already be triggered at this point.

Care diagnostics

careIT Pro automatically derives nursing diagnoses from the acquired data. Of course, the nursing diagnoses can be added or removed manually as desired. The nursing catalogue supplied free of charge or any nursing classifications can be used. The same applies to the catalogue of measures. Whether it is the in-house catalogue, the commercial catalogue of measures or the integrated catalogue already supplied by us - careIT Pro automatically suggests the correct measures including implementation times. To make work easier, it is of course also possible to create standards consisting of several measures, for example if these are required recurrently for certain care problems and/or clinical pictures.

Implementation documentation

The planned nursing measures are clearly presented to the nursing staff and can be commented on or confirmed directly. For this purpose, the users can use different views and, for example, in addition to a daily plan, can also display only the measures relevant for their shift. The software automatically calculates the care measures taken. Ad-hoc adjustments are possible at any time.

Evaluation

The nursing assessment of the patients is regularly repeated by the nursing staff. In this way, the evaluation of the underlying care planning is automatically carried out in the software.

On the basis of the planned, recorded and marked as performed nursing measures, careIT Pro can automatically generate billing-relevant key figures. The software provides both OPS codes with nursing reference as well as all nursing-relevant ICD-10 secondary diagnoses to medical controlling either directly online or in a printable report, which can also be used as a document in the context of case discussions and MD audits. Our projects to date have shown that revenue assurance is up to 75€ higher per case compared to documentation with paper and pen.

The digital patient chart is the interdisciplinary information point within careIT. Here, all vital parameters known from daily nursing practice can be found, which can either be entered manually or recorded via connected spot monitors or special handhelds. In the view, individual vital signs can be selected or deselected in order to adapt the display to the needs of the moment. But also data obtained from (e.g. patient's own) measuring devices, sensors and smart aids are clearly displayed here.

In the medication module, official medication lists, pharmacy lists or house catalogues can be stored. The status of the administration of medication can be documented from the order, to the preparation, control and handing out, to the administration and administration under supervision. In cooperation with our partners, it is even possible to guarantee "closed loop medication".

Wound documentation is an integral part of careIT Pro. In doing so, the module can automatically integrate the wound manager and, in addition to the detailed wound description, also allows direct wound photography on mobile devices (e.g. smartphones, tablets, etc.), thus eliminating the annoying printing and filing of photos. Wound therapy is also integrated into the care planning. Of course, the software also provides complete wound histories and wound reports, into which the photos can be integrated as desired. Thus, nurses can now also calculate wound dimensions in the photo without having to laboriously resort to an old-fashioned paper ruler.

A corresponding form is available for fall documentation, which can be adapted to the specific needs of the facility. The completely digitalised recording of falls offers completely different possibilities of evaluation than would be possible with paper and pencil.

Without nursing key figures, it is difficult to control nursing activities - especially if they are not available in real time. Therefore, careIT Pro offers various key data dashboards for the nursing staff and the management. In this way, shift contents can be planned better and patient flow and staff deployment can be better oriented to current events.

Of course, all recorded data can be evaluated in individual reports that can be used internally (economics, medical controlling, QM, etc.) or externally (follow-up facilities, MD, quality assurance, etc.) by a wide range of interested parties.

Since 1 October 2017, a discharge plan has to be drawn up for each patient in accordance with the framework requirements of the Federal Arbitration Office. Such a planned discharge requires the definition and documentation of criteria (ensuring post-inpatient care, provision of aids, discussions with relatives, etc.) that are necessary for a successful transition.

In the careIT Pro nursing expert software, these criteria can be created as milestones for all persons involved in the care process and displayed transparently (dashboard). Furthermore, the software monitors possible deviations and implausibilities in the discharge planning. Checklists and automatic process progress analyses also show on the occupancy dashboard, in addition to the current occupancy, possible or planned discharges, as well as milestones that still need to be completed beforehand. In this way, all members of the therapeutic team always have an overview of the most important milestones of a patient up to the point of discharge and thus also have the adjusting screws for an efficient and sustainable patient flow in their hands.

More and more intelligent sensors and smart care aids are available on the market. careIT Pro integrates such technologies and thereby automates documentation tasks. In addition, any patterns can be recognised on this database and preventive care interventions can be generated. Thus, a digital care expert software such as careIT Pro is only the first, necessary step if one wants to be able to generate data from smart care aids in the future and make it usable in the daily setting.

Which nurse in the hospital does not know the situation? A situation with a patient requires the doctor's attention and reaction. But the doctor is not available where he is at the moment. Via an integrated messenger function, the nurse can contact the doctor in careIT Pro. The communication is related to the patient and is automatically added to the patient's file. This makes the communication more binding. The nurse can prove that he has informed the doctor about a situation in time and in detail. If necessary, the doctor can look at wound photos or similar in real time and react immediately. Both professions benefit and, of course, especially the patient.  

Touch displays open up completely new possibilities for the rapid recording of information. With the graphical documentation Grafixx from careIT Pro, a lot of relevant information from the nursing observation can not only be recorded quickly. This information is also displayed graphically on a "virtual patient/resident" and thus allows a holistic, nursing view.

All nursing information in careIT Pro is a valuable database for the care of the individual patient/resident. However, they are also important process indicators for controlling the nursing processes and nursing care by the nursing management. In addition, they provide the important basis for staffing, staff control and budget negotiations. In the careIN module, you receive all important information of your own ward, department or facility as a key figure dashboard.