Assistência de enfermagem no planejamento para alta hospitalar : subsídios para continuidade do cuidado.

Abstract

According to the hospital discharge planning, that involves the entire multidisciplinary team who was in contact with the patient, we emphasize the role of nursing in the planning development, since it is the area that is ahead of care. Considering as fundamental to develop nursing care through guidelines and an effective communication with the primary care network. Not only to keep the patientes informed about their health and care, but how to let the reference unit aware of their return to home, so the importance of using discharge note and counterference is a way to maintain a link between the hospital and primary care network to keep the communication about patients, for the care be interconnected between the two levels to a continuity care. The general objective at this paper was to know the process of planning, execution and monitoring cares of discharge planning and as specific objectives: to analyze how to lead the discharge planning of patients/family for nurses; to identify the involvement, the responsability and the actions nurse in the articulation between hospital attention and basic atention and check the atuation of nurse front of the continuity of care after discarge planning. It was done using bibliographic references and articles on the topic of choice, the subject is presented through a descriptive and exploratory study with a qualitative approach, after data collection and questionnaires interpretation of four hospital nurses, ten nurses working in public health and seven patients were ounterreference to health services. The discussion was elaborated through the discourse analysis. The nurses interviewed mention the importance of the nursing role in the process of discharge planning and the follow-up after patient discharge, as always seek the best care to patients, but realize that there are deficiencies in the discharge planning process and weaknesses in communication between hospital x primary care network to provide continuity of care to patients. This paper explains the importance of using the hospital discharge planning indicating the need to follow-up care to the patient still undergoing rehabilitation, aimed at health quality in the continuity of their care, keeping the patient always oriented; preventing damage or possible readmissions.