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Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Coronary Care and Cardiology Nursing
You say what you saw on the monitor and at the bedside. Hysio organises it into an intake, care encounter, ward round report or handover.
A structured report in your professional terminology
From care encounter to report
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
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Record the conversation and clearly state your own findings and agreed actions.
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More attention for the conversation, less typing afterwards.
State relevant information, your own findings and agreed actions aloud so you can find them in your report.
The information appears under the headings of your chosen report format, so you can review each section.
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
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Quick answer
Four documentation formats for the CCU and the cardiology ward: admission, short care encounter, ward round and handover.
An overview of what Hysio records in the CCU. You read every report back before it goes into the record.
There are four formats. The Intake is for the cardiac admission. The Care Encounter Report is for a short contact during the shift. Ward Round & Observation records your input at the ward round. The Handover is for an internal transfer. With voice-driven reporting, you say after the contact what you saw and did, and you read the text back. [3] [4] [5] [6] [1]
The Intake turns one cardiac admission conversation or a direct dictation into an intake report. There are fixed sections: summary, context and sources, data collection, professional assessment, follow-up and additional information. What you did not ask stays open. Hysio does not make a diagnosis or an indication. [3]
This format turns one short dictation into a traceable care encounter report. Think of a check, a medication round or a complaint at night. What the client reports, the monitor values, the care and medication, the response and the open follow-up stay separate per moment. That way every contact can be read back separately. [4]
This format organises your input at the ward round and the observation moment that goes with it. Observations, values, stated decisions, proposals and actions stay with whoever said them. Each item shows the reference time and the status. That way you can see later what was decided and what was only proposed. [5]
The Handover turns one current dictation and at most three relevant source files into a text for the receiving ward. The cardiac condition, the admission context, ongoing care, risks, pending results and the follow-up each get a fixed place. For each point, the source and the reference time stay visible. [6]
You ask about the complaint, the course, the medical history and the medication. You state what you see and measure yourself. The Intake puts that under the right headings. What the client tells you and what you establish stay separate. Your assessment stands apart, as your assessment. [3]
Record briefly: what was the reason, what did you see or measure, what did you do and how did the client respond. State the time. Hysio turns it into a care encounter report with the fixed headings. You make a following contact into a new report, so that the line stays clear. [4]
After the ward round, say what you contributed and what the doctor said. For decisions, name who decided. Proposals that have not yet been adopted stay proposals. Hysio keeps those differences and does not turn an idea into a plan. [5]
A Starter plan is €20 per month, excl. VAT. The price is the same for every documentation format and any number of contacts. When comparing, also count the time you spend reading back. You decide what you transfer to the record. [7]
In the CCU, clients are often close together, so watch who is listening in. Record where possible and only what is needed for this client. Your hospital decides who may read and approve the report. A family member at the bedside does not get access because of it. [9]
Nursing is an article 3 profession under the Wet BIG. The title is protected by law and you must be in the BIG register to use it. The profession falls under statutory disciplinary law. In your report, you therefore keep observation, interpretation and agreement recognisably apart. [12]
Both depend on competence, an instruction from an authorised healthcare professional and the Besluit functionele zelfstandigheid (functional independence decree). So only record what you actually carried out and on whose instruction. What still needs to happen, you name as an open point. Hysio does not add a procedure you did not mention. [14] [15]
The recipient wants to know how the client is doing now. State the cardiac condition, what is ongoing, which risks there are and which results are still pending. The background of the admission is added briefly. Hysio puts it in a fixed order, so that the colleague quickly finds what is needed. [6]
Use the client's own words as much as possible and say that it is a report. Also say when the complaint began. Hysio does not turn a description into a medical term. If you want to interpret it yourself, state it as your assessment. [3]
State the value, the unit and the moment you read it. Also say if a value differs from what you expected and what you did then. Hysio does not calculate an average and draws no conclusion. The values go under observations, your actions under care delivered. [4]
Say literally whether something was decided or only proposed. Name who said it. Hysio puts decisions under discussed plan and leaves proposals as proposals. That way an idea at the ward round does not quietly become an instruction. [5]
Yes, at most three relevant source files alongside your own dictation. Choose what the recipient really needs, such as a recent result. Hysio only takes from those files what fits the handover, with the source attached. Check that nothing from another client has slipped in. [6]
Name the medicines the client uses, with the source: the client, a list or the pharmacy. Say what you could not verify. Hysio does not fill in a dose and does not make a medication overview that you have not checked. Read this part back extra carefully. [3]
When you type, you write the record text straight away, often later in the shift. When you dictate, you say straight after the contact what happened, and Hysio organises it. Reading back stays your task. Compare how much you need to correct and whether the text is clear for the next shift. [10]
Choose a few fictional situations, for example an admission with chest pain and a rhythm alarm at night. Record them as you would in a real shift. See whether reports, values and actions stay properly apart and how much you need to adjust. [8]
The guideline sees documentation as an ongoing part of all phases of the nursing process. It is about establishing care needs, giving care, evaluating and monitoring care, and handing over care to other healthcare professionals. For each contact, only note what was established then, and keep fact and assessment apart. [13]
First say what you gave, how much and when. Then say what you saw or measured, also with a time. Hysio sets administration and response side by side, but draws no link that you do not mention. If you are unsure about the effect, say so. [4]
A value only means something if you know when it was measured. That is why the ward round report shows the moment for every value. That way a colleague does not accidentally read an old value as the current one. So always state the time when you record. [5]
Say which test was done or requested and that the result is not yet known. Name who follows up the result, if that was agreed. Hysio does not fill in a result. In the handover it appears under open actions. [6]
Record what you do know and from whom. Information from family or from a referral, you state with that source. What is unknown stays unknown. Hysio does not fill in the medical history from assumptions. Ask later for what is missing. [3]
Describe what you saw, when, and what you then did or whom you called. Say it as you observed it. Hysio does not assess the rhythm and does not add a classification. An interpretation by the doctor, you state with the doctor as the source. [4]
Everyone who contributed something that goes into the report. When recording, say who said what: you, the cardiologist or another colleague. Hysio keeps track of that and does not attribute a statement to someone else. That way the ward round is represented fairly. [5]
State a risk as it was discussed or established, with the source. Hysio makes no risk assessment of its own and does not add a risk. In the handover it appears with the current care. Discuss with your team which risks always belong there. [6]
No, there is no direct link. After reading back, you copy the passage you need into your hospital's record. Then check once more that you have the right client. Follow your ward's agreements when doing so. [11] [10]
Read the report from top to bottom and compare it with your notes or the monitor. Are the times, values and units right? Is every statement with the right person? Only then do you approve it. [10]
They each have their own function: recording medical terms, structuring data and exchanging nursing information. For the acute care chain there is also the Informatiestandaard Acute Zorg (acute care information standard). Which codings and standards your organisation uses follows from the local agreements. A general list does not prove that they are all in your record. [16] [17] [18] [19]
In a section of its own, separate from the data you collected. When recording, say clearly what your assessment is. Hysio puts it there, without making it stronger or weaker. That way a colleague reads straight away what is fact and what is your judgement. [3]
Say when the alarm went off, what you saw in the client and what you did. Also say if you did not assess the alarm yourself. Hysio does not decide whether an alarm was justified. What the doctor thought of it, you state with the doctor as the source. [4]
Name the questions or actions that were not completed, and who takes them up if that is known. In the ward round report they go under follow-up. Hysio does not turn an open question into a decision. That way the next shift knows what still needs to happen. [5]
It shows what has already been handed over and what has not. When recording, say what you passed on verbally and to whom. Hysio does not write that something was taken over if you do not mention it. That way the status is still right afterwards. [6]
Name the family member as the source, for example the partner or a daughter. What they say about the complaints or the medication then stays separate from what the client says. Hysio does not turn their account into an established fact. Check what you consider important. [3]
Make a separate care encounter report for each contact. Always state the time and the reason. Voice-driven admin works best with short dictations straight after each contact. That way you prevent values or responses from different moments getting mixed up. [4]
No. Hysio only records what was discussed and decided. A change of plan only appears once someone has stated it. When recording, name who decided. What you think the next step is yourself, you state as a proposal. [5]
First find out where the error comes from: your dictation or the organisation of the text. Then correct only that part. If the same value also appears in the summary or the handover, adjust that too. Hysio never makes substantive choices itself. [10]
Mark what you cannot hear properly and do not guess. Play the recording again or check with the colleague who was there. Do not fill in a number because it seems logical. A visible gap is safer than an assumption in a cardiac report. [10]
Use the Handover and focus on what the ward needs to know. How is the condition now, what is ongoing, what needs to be checked and which results are still to come. The admission context is added briefly. Hysio does not choose a priority; you do that with your colleague. [6]
The Intake belongs to the admission, with the full data collection. The care encounter report is for a short moment after that. They have a different purpose and a different length. Choose the format that fits the contact you are recording. [3]
State what the client says about the pain and when it began. Say what you saw and measured, and what you did or whom you alerted. Hysio does not interpret the pain and does not add a cause. You state the response to your action with a time. [4]
Say who mentioned the value and which moment it is from. A value from the lab is a different source than your own measurement. Hysio keeps those sources apart. That way you can trace later where each number came from. [5]
Only record what the recipient needs now. The rest is already in your earlier reports. The Handover has fixed headings, so that nothing important is missing. Check that the open actions are clear. [6]
Only state what was really agreed, such as checks or a conversation with the doctor. A plan you still need to discuss is an open point. Hysio does not turn an idea into an agreement. Name who takes something up, if that is known. [3]
Use a care encounter report. State the time, what you checked and what you found. Say what you did if something deviated. Hysio does not decide whether a finding is normal. That judgement stays with you and the treatment team. [4]
Yes, that is what this format is for. First say what you saw and measured, and then what was discussed at the ward round. AI reporting helps put those two in one report, each with its own source. Do check that the reference time is right for every value. [5]
Note for a week how much time you spend reporting after a contact. Then do the same with Hysio, on comparable shifts. Count the reading back and correcting too. Also check whether the text has become more complete, because that counts just as much as minutes. [10]
First choose one format, for example the care encounter report, and practise with fictional cases. Make agreements with your manager about privacy and about who approves a report. After a few weeks, discuss what went well. Only then add the other formats. [10] [9]
Hysio creates the report. You remain responsible for what you save in the record.