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Lecture Nursing documentation using electronic health records: Chapter 12 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 12 - Advanced EHR functionality. After completing Chapter 12, the students will be able to: Use EHR to order diagnostic tests, carry out a chart evaluation, use a new note to create an addendum to a nurse note, carry out printing a nurse note, carry out exporting and printing elements of a patient’s chart. | Chapter 12 Advanced EHR Functionality © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 12 Content LO 12.1 Diagnostic Tests LO 12.2 Chart Evaluations LO 12.3 Addenda to a Nurse Note LO 12.4 Printing a Nurse Note LO 12.5 Exporting and Printing the Chart LO 12.1 DIAGNOSTIC TESTS LO 12.1 Diagnostic Tests Processing diagnostic tests Provider orders test If Computerized Physician Order Entry (CPOE) not in use, personnel submit order to appropriate department Imaging Lab Diagnostic department performs test Results entered into EHR Results available to nurse/provider LO 12.1 Diagnostic Tests Communication of diagnostic test results Most EHRs have alerts for abnormal results Primary provider must be notified of most abnormal results Nursing judgment required Nurse must know underlying etiology and patient trends LO 12.1 Diagnostic Tests Critical tests Delineated by facility Requires that provider notified of results even if normal Critical results Delineated by | Chapter 12 Advanced EHR Functionality © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 12 Content LO 12.1 Diagnostic Tests LO 12.2 Chart Evaluations LO 12.3 Addenda to a Nurse Note LO 12.4 Printing a Nurse Note LO 12.5 Exporting and Printing the Chart LO 12.1 DIAGNOSTIC TESTS LO 12.1 Diagnostic Tests Processing diagnostic tests Provider orders test If Computerized Physician Order Entry (CPOE) not in use, personnel submit order to appropriate department Imaging Lab Diagnostic department performs test Results entered into EHR Results available to nurse/provider LO 12.1 Diagnostic Tests Communication of diagnostic test results Most EHRs have alerts for abnormal results Primary provider must be notified of most abnormal results Nursing judgment required Nurse must know underlying etiology and patient trends LO 12.1 Diagnostic Tests Critical tests Delineated by facility Requires that provider notified of results even if normal Critical results Delineated by facility Grossly abnormal results that require immediate provider notification LO 12.1 Diagnostic Tests Required documentation Name of primary care provider notified Date and time notified Results of test reported Provider’s response No new orders New orders received LO 12.1 Diagnostic Tests Failure to communicate lab results as indicated May constitute nursing negligence Follow facility chain-of-command policy if unable to reach provider LO 12.2 CHART EVALUATIONS LO 12.2 Chart Evaluations Chart evaluations Provide mechanism for determining when health promotion and disease prevention interventions needed Screening tests/exams Immunizations Based on gender, age, personal and family health history Improves adherence to practice guidelines LO 12.2 Chart Evaluations Use of guideline reminders Patient has right to refuse Document refusal Provider uses clinical judgment for recommendations LO 12.3 ADDENDA TO A NURSE NOTE LO 12.3 Addenda to a Nurse Note Addendum = late entry Used to add .