Lecture Nursing documentation using electronic health records: Chapter 11 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 11 - Nurse note documentation, level 3. After completing Chapter 11, the students will be able to: Carry out documentation of patient education and response, identify patient response to interventions, carry out documentation re-assessment/revision of goals, use Todo/Reminders within the Nurse Note.

Chapter 11

Nurse Note Documentation

Level 3

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Chapter 11 Content

LO 11.1 Teaching (Patient Education)

LO 11.2 Evaluation

LO 11.3 Reassessment

LO 11.4 F/U-REM (Follow-up

Reminders/ToDo List)

EDUCATION)

LO 11.1 Teaching (Patient

Education)

• Patient education

– Key intervention for nursing

– SpringCharts has specific area focused on

documentation of instruction

• Intervention component of SOAPIER

LO 11.2 Evaluation

• Evaluation

– Patient progress toward meeting outcomes

must be evaluated routinely

• Determine if nursing interventions are effective

• Determine if outcomes have been met or if the plan of care requires revision

LO 11.3 Reassessment

• Reassessment

– Response to intervention

• Analgesic

• Diuretics

– Post-procedure

• Surgery

• Heart catheterization

REMINDERS/TODO LIST)

LO 11.4 F/U-REM (Follow-up

• Follow-up reminders

– Allows nurse to set reminders for follow-up

care

– Useful for discharge disposition