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Lecture Nursing documentation using electronic health records: Chapter 5 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 5 content: Recording vital signs, documenting telephone calls, creating a letter to a patient or about a patient, creating a letter unrelated to a patient, sending a test report to a patient, Creating an excuse note and order form for a patient, using practice guidelines, using “my websites”, using the calculator utilities. | Chapter 5 Fundamental Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 5 Content LO 5.1 Recording vital signs LO 5.2 Documenting telephone calls LO 5.3 Creating a letter to a patient or about a patient LO 5.4 Creating a letter unrelated to a patient LO 5.5 Sending a test report to a patient LO 5.6 Creating an excuse note and order form for a patient LO 5.7 Using practice guidelines LO 5.8 Using “My Websites” LO 5.9 Using the calculator utilities LO 5.1 RECORDING VITAL SIGNS © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill LO 5.1 Recording Vital Signs Vital sign monitoring Outpatient: ongoing monitoring between visits Inpatient: frequent vital signs after procedures or with unstable patient Graphing vital signs Allows visual representation of trends LO 5.2 DOCUMENTING TELEPHONE CALLS LO 5.2 Documenting Telephone Calls Phone calls requiring documentation To patient Education Follow-up post procedure Communicate . | Chapter 5 Fundamental Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 5 Content LO 5.1 Recording vital signs LO 5.2 Documenting telephone calls LO 5.3 Creating a letter to a patient or about a patient LO 5.4 Creating a letter unrelated to a patient LO 5.5 Sending a test report to a patient LO 5.6 Creating an excuse note and order form for a patient LO 5.7 Using practice guidelines LO 5.8 Using “My Websites” LO 5.9 Using the calculator utilities LO 5.1 RECORDING VITAL SIGNS © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill LO 5.1 Recording Vital Signs Vital sign monitoring Outpatient: ongoing monitoring between visits Inpatient: frequent vital signs after procedures or with unstable patient Graphing vital signs Allows visual representation of trends LO 5.2 DOCUMENTING TELEPHONE CALLS LO 5.2 Documenting Telephone Calls Phone calls requiring documentation To patient Education Follow-up post procedure Communicate testing/appointment details To other healthcare providers Prescriptions Change in condition Diagnostic testing results Clarification of orders LO 5.2 Documenting Telephone Calls Privacy considerations Must not release private health information without consent Follow policy for giving information Documentation requirements Who When What Response LO 5.3 CREATING A LETTER TO A PATIENT OR ABOUT A PATIENT LO 5.3 Creating a Letter Letter creation Rarely done by nurses in inpatient setting Outpatient setting Inform patient of testing, appointments Report consultation from one provider to another LO 5.4 CREATING A LETTER UNRELATED TO A PATIENT LO 5.4 Creating Letter Unrelated to a Patient Rarely done by nurses Hospitals, attorneys, accountants LO 5.5 SENDING A TEST REPORT TO A PATIENT LO 5.5 Sending a Test Report to a Patient Tests reports created for patients Post or e-mail Contain: Test description Test result Text can be added that identifies problem areas and recommendations LO 5.5 Sending a