tailieunhanh - Lecture Nursing documentation using electronic health records: Chapter 7 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 7 - Ambulatory healthcare. After completing Chapter 7, the student will be able to: Describe the role of an ambulatory nurse, use SpringCharts to create an office visit note, use SpringCharts to modify an office visit note, carryout preparing an addendum to the office visit note. | Chapter 7 Ambulatory Healthcare © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 7 Content LO The Ambulatory Nurse LO Building an Office Visit Note LO Modifying the Office Visit Note LO Creating an Addendum LO THE AMBULATORY NURSE LO The Ambulatory Nurse Ambulatory nursing Increased demand due to movement of patient care to outpatient setting Episodic care < 24 hours Highly interdisciplinary LO The Ambulatory Nurse Unique set of nursing skills Assessment Health promotion Health maintenance Patient education Patient advocacy Collaboration Financial aspects of patient care American Association of Ambulatory Care Nurses (AAACN) LO The Ambulatory Nurse Nurse practitioners Advanced practice nurses Licensed independent practitioners Advanced education Holistic practice Scope of practice regulated by individual states Assigning medical dx Prescribing medications and treatments LO The Ambulatory Nurse Research findings: Nurse | Chapter 7 Ambulatory Healthcare © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 7 Content LO The Ambulatory Nurse LO Building an Office Visit Note LO Modifying the Office Visit Note LO Creating an Addendum LO THE AMBULATORY NURSE LO The Ambulatory Nurse Ambulatory nursing Increased demand due to movement of patient care to outpatient setting Episodic care < 24 hours Highly interdisciplinary LO The Ambulatory Nurse Unique set of nursing skills Assessment Health promotion Health maintenance Patient education Patient advocacy Collaboration Financial aspects of patient care American Association of Ambulatory Care Nurses (AAACN) LO The Ambulatory Nurse Nurse practitioners Advanced practice nurses Licensed independent practitioners Advanced education Holistic practice Scope of practice regulated by individual states Assigning medical dx Prescribing medications and treatments LO The Ambulatory Nurse Research findings: Nurse practitioners Produce outcomes comparable to physicians Provide cost-effective care Rank higher than physicians in patient satisfaction LO BUILDING AN OFFICE VISIT NOTE LO Building an Office Visit Note Subjective Components of Office Visit Chief complaint Primary reason patient seeks care Best documented as patient quote Present illness Onset Duration Severity Aggravating and alleviating factors Review of systems Specific data about each body system LO Building an Office Visit Note Subjective Components of Office Visit (cont.) Health History Obtained on initial visit Reviewed and updated with subsequent visits Promotes accurate diagnosis LO Building an Office Visit Note Objective components of Office Visit Vital signs Examination LO Building an Office Visit Note Other components of Office Visit Medical diagnosis Medications Epocrates Website Drug interaction/allergy alerts SureScripts Web-based e-prescribing clearinghouse Tests Procedures Other treatment .