Lecture Nursing documentation using electronic health records: Chapter 5 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 5 content: Recording vital signs, documenting telephone calls, creating a letter to a patient or about a patient, creating a letter unrelated to a patient, sending a test report to a patient, Creating an excuse note and order form for a patient, using practice guidelines, using “my websites”, using the calculator utilities.

Chapter 5

Fundamental Documentation

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McGraw­Hill

Chapter 5 Content

LO 5.1 Recording vital signs

LO 5.2 Documenting telephone calls

LO 5.3 Creating a letter to a patient or about a patient

LO 5.4 Creating a letter unrelated to a patient

LO 5.5 Sending a test report to a patient

LO 5.6 Creating an excuse note and order form for a

patient

LO 5.7 Using practice guidelines

LO 5.8 Using “My Websites”

LO 5.9 Using the calculator utilities

LO 5.1 RECORDING VITAL

SIGNS

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McGraw­Hill

LO 5.1 Recording Vital Signs

• Vital sign monitoring

– Outpatient: ongoing monitoring between visits

– Inpatient: frequent vital signs after

procedures or with unstable patient

• Graphing vital signs

– Allows visual representation of trends

LO 5.2 DOCUMENTING TELEPHONE

CALLS

• Follow-up post procedure

• Communicate testing/appointment details– To other healthcare providers

• Prescriptions

• Change in condition

• Diagnostic testing results

• Clarification of orders

LO 5.3 CREATING A LETTER TO A

PATIENT OR ABOUT A PATIENT

LO 5.3 Creating a Letter

• Letter creation

– Rarely done by nurses in inpatient setting

– Outpatient setting

• Inform patient of testing, appointments

• Report consultation from one provider to another

LO 5.4 CREATING A LETTER

UNRELATED TO A PATIENT

LO 5.4 Creating Letter Unrelated

to a Patient

• Rarely done by nurses

• Hospitals, attorneys, accountants

LO 5.5 SENDING A TEST REPORT

TO A PATIENT

LO 5.5 Sending a Test Report to

– Text can be added that identifies problem

areas and recommendations

LO 5.5 Sending a Test Report to

a Patient

• Privacy concerns:

– Transmitting private health information via

e-mail risks disclosure to unauthorized

individuals

• Travels over the internet

• May be accidentally sent to the wrong e-mail address

• Nurses should adhere to facility policy to

protect themselves against liability

LO 5.6 CREATING AN EXCUSE

NOTE AND ORDER FORM FOR A

PATIENT

LO 5.6 Creating an Excuse note

and Order Form for a Patient

LO 5.7 USING PRACTICE

GUIDELINES

LO 5.7 Using Practice

Guidelines

• Practice guidelines

– Statements used to direct care that indicate

evidence-based diagnosis and treatment for

clinical conditions

– Best practice/evidence-based practice

– Accessible from National Guideline

Clearinghouse online

– May be attached to Nurse Note for easy

accessibility

LO 5.8 USING “MY WEBSITES”

LO 5.8 Using “My Websites”

LO 5.9 USING THE CALCULATOR

UTILITIES

LO 5.9 Using the Calculator

• Input Last Monthly Period (LMP)

• Calculates fetal age and EDD– Simple

• Routine mathematical calculations