Chapter 9 - Routine documentation. After completing Chapter 9, the students will be able to: Use the ToDo List feature, use internal messages, carry out accessing and completing the patient’s immunization record, carry out creating and distributing a patient instruction sheet, use the draw program to develop illustrations to enhance documentation.
Trang 1Chapter 9
Routine Documentation
© 2012 The McGrawHill Companies, Inc. All rights reserved.
McGrawHill
Trang 2Chapter 9 Content
LO 9.1 ToDos and Reminders
LO 9.2 Internal Messages
LO 9.3 Immunization Record
LO 9.4 Patient Instructions
LO 9.5 Draw Program
Trang 3LO 9.1 TODOS AND
REMINDERS
Trang 4LO 9.1 ToDos and Reminders
• Electronic task list
– Personal use
– May be sent to others
– May be scheduled to send at later date
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Trang 6LO 9.2 Internal Messages
• Internal Messages
– Intra- and interoffice mail function
– May be patient related or non-patient related
• Patient related saved in patient’s chart
• Non-patient related - archived
– Urgent messages
• Discreet method of communication
• Eliminates time spent looking for co-worker
• Not saved/stored
• Processed centrally
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RECORD
Trang 8LO 9.3 Immunization Record
• Immunization history
– Important for both adult and pediatric patients
– Inpatient and outpatient setting
• Inpatient setting
– Adults must be offered influenza and
pneumococcal vaccines if meet certain criteria
• Healthy People 2020
– Goal to increase the numbers of adults over 65
who have annual influenza vaccines and who are
immunized once with the pneumococcal vaccine
Trang 9LO 9.3 Immunization Record
• Vaccine Information Statements (VIS)
– Developed by the Centers for Disease Control and Prevention (CDC)
– Explains the risks and benefits of vaccines
– Must be given to a patient or guardian before
administration of certain immunizations
Trang 10LO 9.3 Immunization Record
• Required documentation for vaccines
– Date of edition of the VIS
– Date the VIS is provided to the patient or legal representative
– Date of administration
– Manufacturer
– Lot number
– Name, title, and address of the individual
administering the vaccine (may be kept in
office file)
Trang 11LO 9.4 PATIENT
INSTRUCTIONS
Trang 12LO 9.4 Patient Instructions
• Written instructions augment verbal
education
• Reputable patient education Websites:
– Food and Drug Administration Website (
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM111085
)
– National Institutes of Health Medline Plus
Webpage ( http://
Trang 13LO 9.4 Patient Instructions
• Nurse ultimately responsible
– Content of patient instructions
– Evaluation and documentation of patient
understanding
Trang 14LO 9.5 DRAW PROGRAM
Trang 15LO 9.5 Draw Program
• Photographs and drawings
– Supplement narrative descriptions
• Wound stages
• Effectiveness of treatment
• Injuries/conditions present on admission
Trang 16LO 9.5 Draw Program
• Deficit Reduction Act of 2005
– Identification of certain conditions
• Increase cost of care
• Preventable through use of EBP
– CMS (2008)
• Withhold payment for these hospital acquired conditions (HAC)
• Increasingly important to document if present on admission (POA)
Trang 17LO 9.5 Draw Program
• Photos useful with the following POA
conditions
– Pressure ulcers
– Injuries due to falls
– Vascular catheter-associated infections