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.
Trang 1Chapter 7
Ambulatory Healthcare
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McGrawHill
Trang 2Chapter 7 Content
LO 7.1 The Ambulatory Nurse
LO 7.2 Building an Office Visit Note
LO 7.3 Modifying the Office Visit Note
LO 7.4 Creating an Addendum
Trang 3LO 7.1 THE AMBULATORY
NURSE
Trang 4LO 7.1 The Ambulatory Nurse
• Ambulatory nursing
– Increased demand due to movement of
patient care to outpatient setting
– Episodic care < 24 hours
– Highly interdisciplinary
Trang 5LO 7.1 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)
Trang 6LO 7.1 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
Trang 7LO 7.1 The Ambulatory Nurse
• Research findings:
– Nurse practitioners
• Produce outcomes comparable to physicians
• Provide cost-effective care
• Rank higher than physicians in patient satisfaction
Trang 8LO 7.2 BUILDING AN OFFICE
VISIT NOTE
Trang 9LO 7.2 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
Trang 10• Subjective Components of Office Visit
(cont.)
– Health History
• Obtained on initial visit
• Reviewed and updated with subsequent visits
• Promotes accurate diagnosis
Trang 11LO 7.2 Building an Office Visit
Note
• Objective components of Office Visit
– Vital signs
– Examination
Trang 12• Other components of Office Visit
– Medical diagnosis
– Medications
• Epocrates Website
• Drug interaction/allergy alerts
• SureScripts Web-based e-prescribing clearinghouse
– Tests
– Procedures
– Other treatment
– Follow-up/Reminders
Trang 13LO 7.3 MODIFYING THE OFFICE
VISIT NOTE
Trang 14• Modification of OV note
– Allows various disciplines to document during
one encounter
– Entries initialed
– Permanently signed and locked at end of
encounter
Trang 15LO 7.4 CREATING AN
ADDENDUM
Trang 16LO 7.4 Creating an Addendum
• Once permanently signed and locked – no
changed to office visit
• Addendum
– Allows for entry of information after the fact
• Clarification
• Addition of inadvertently omitted information