Creation of the guideline for collaborative nursing practice in the community care : focused on ambulatory and home health care agency

本研究旨在了解各机构间护理人员为患者提供医疗服务的实际合作情况，并提出促进合作的建议。为了建立医院内部各部门之间的合作，它被发现是必要的，护士管理人员了解的必要性，继续护理，选择核心成员谁拥有家庭医疗保健知识，并让整个医院参与。研究还发现，大型巡回护理站可以积极参与提供出院计划在医院，而有出院计划护士的医院有积极的合作。对于慢性疑难杂症，有必要在门诊设立咨询室，并将门诊信息传递给当地公共卫生护士和巡回护理站。

A research was performed to figure out the actual situation of the collaboration of nurses among each institution for the medical treatment of patients and to provide recommendations for facilitating the collaboration. In order to build collaboration among the departments inside hospital, it was found out to be necessary that nurse administrators understand the necessity of continuing nursing care, selecting core members who have knowledge of home medical care and getting the entire hospital involved. It was also found out that the large scale visiting nursing care stations can be actively involved in providing discharge planning at the hospitals, while there are active collaborations in the hospitals where there are discharge planning nurses. As for intractable chronic diseases, it was found out to be necessary to set up a counseling room at outpatient department, and to transmit information from the outpatient department to local public health nurses and visiting nursing care station.