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

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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

– 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

– 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

– May constitute nursing negligence

– Follow facility chain-of-command policy if

unable to reach provider

LO 12.2 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

• Addendum = late entry

– Used to add information omitted from original

note

– Includes information about actual date and

time of occurrence

LO 12.4 PRINTING A NURSE

NOTE

LO 12.4 Printing a Nurse Note

• Rarely required

– Nurse note may be printed when transferring

patient to another facility without EHR

• Follow facility policy for release of records

LO 12.5 EXPORTING AND

PRINTING THE CHART

• Legal considerations

– The Medical Records Confidentiality Act of

1995

• First comprehensive federal legislation protecting personal health information

• Requires individuals to consent to release of health information for treatment or payment

– Individual state laws also regulate

confidentiality of health records

– In most cases, patient health records can only

be released to others with the patient’s

consent

– Healthcare facilities have ‘release of records’

forms

• Privacy of records

– Federal law requires healthcare providers to

employ security measures to ensure privacy

of protected health information during

electronic transmission