EVL 6.2
Ketenzorg organiseren
en bewaken, duurzame
samenwerkingsverbande
n aangaan
Chantal Ouwerkerk
,
, Inhoud
1. De patiëntencategorie en het ketenproces........................................................................................2
2. Twee voorbeeld casussen vanuit de praktijk......................................................................................3
Casus 1................................................................................................................................................3
3. De ketenzorg......................................................................................................................................4
Het proces..........................................................................................................................................4
Recente ontwikkelingen in de ketenzorg met betrekking tot de verpleegkundigeoverdracht...........5
Knelpunten en mogelijke oplossingen................................................................................................5
Mijn Visie op de ketenzorg.................................................................................................................6
Beleid..................................................................................................................................................7
4. Wet- en regelgeving...........................................................................................................................7
5. Ethische dilemma’s.............................................................................................................................9
6. De verpleegkundige regierol in de keten..........................................................................................10
7. Het verbetervoorstel........................................................................................................................10
Feedback vanuit de ketenpartner uit de regio..................................................................................11
8. Het artikel.........................................................................................................................................13
Bibliografie...........................................................................................................................................14
Bijlagen.................................................................................................................................................16
Bijlage 1 feedbackformulier..............................................................................................................16
Bijlage 2 beoordelingsformulier versie 2..........................................................................................16
Bijlage 3 beoordelingsformulier versie 1..........................................................................................19
1. De patiëntencategorie en het ketenproces
De patiënten categorie die ik heb gekozen is; somatische cliënten die uit het ziekenhuis komen, naar
huis toe gaan en thuiszorg nodig hebben. Oftewel thuiszorgbehoevende cliënten. Vaak zijn dit
kwetsbare ouderen. De betrokkene bij deze patiënten zijn:
de afdelingsarts,
de transferverpleegkundige,
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