Lecture Nursing documentation using electronic health records: Chapter 4 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 4 - Nurse note documentation, level 1. After completing Chapter 4, the students will be able to: Describe the components of a nurse note, carry out documentation of a nurse note, use chief complaints, carry out documentation of vitals (vital signs), carry out documentation of an exam (assessment).

4-1 Chapter Nurse Note Documentation Level McGraw­Hill © 2012 The McGraw­Hill Companies, Inc. All rights reserved 4-2 Chapter Content LO 4.1 Nurse Note Components LO 4.2 Documenting a Nurse Note – Level LO 4.3 Chief Complaints LO 4.4 Vitals (Vital Signs) LO 4.5 Exam (Physical Assessment) 4-3 LO 4.1 NURSE NOTE COMPONENTS 4-4 LO 4.1 Nurse Note Components • Nursing Documentation – Facilitated by Charting by Exception (CBE) – EHRs provide for rapid access to patient information • Nurse Note – Area of chart for nursing documentation 4-5 LO 4.1 Nurse Note Components • SOAPIER S = Subjective O = Objective A = Assessment P = Plan I = Intervention E = Evaluation R = Revision/resolution 4-6 LO 4.2 DOCUMENTING A NURSE NOTE 4-7 LO 4.2 Documenting a Nurse Note • Components of SpringChart Nurse Note – – – – – – – – – – CC (Chief Complaint), Vitals, Exam (Physical Assessment) Dx (NANDA-I/Diagnosis) NOC (Nursing Outcomes Classification) NIC (Nursing Interventions Classification) Test (Tests) Proc (Procedures) Teaching Evaluation Reassess (Reassessment) 4-8 LO 4.2 Documenting a Nurse Note • Documentation methods – Pop-up text – Copy previous notes – Type 4-9 LO 4.3 CHIEF COMPLAINTS 4-10 LO 4.3 Chief Complaints • Chief Complaint – Issue that prompted patient to seek care – Subjective – Should be documented in patient’s words as quote 4-11 LO 4.4 VITALS (VITAL SIGNS) 4-12 LO 4.4 Vitals (Vital Signs) • Traditional vital signs – – – – Temperature Blood pressure Pulse Respirations • Other measurements included by SpringCharts – – – – Height Weight Body mass index (BMI) Body fat percentage 4-13 LO 4.4 Vitals (Vital Signs) • Vitals – Objective measurements – May add three additional measurements such as: • Pulse oximeter • Pain scale • Height of fundus in pregnant women 4-14 LO 4.4 Vitals (Vital Signs) • Vitals graphs – Blood pressure – Height – Weight – BMI • Includes children’s growth charts 4-15 LO 4.5 EXAM (PHYSICAL ASSESSMENT) 4-16 LO 4.5 Exam (Physical Assessment) • Physical assessment – Charting by Exception (CBE) • May indicate normal systems – must know facility definition of “normal” • Abnormal findings require additional detail • Sign and Lock – Upon completion of documentation in Nurse Note .. . 4- 2 Chapter Content LO 4. 1 Nurse Note Components LO 4. 2 Documenting a Nurse Note – Level LO 4. 3 Chief Complaints LO 4. 4 Vitals (Vital Signs) LO 4. 5 Exam (Physical Assessment) 4- 3 LO 4. 1 NURSE... 4- 9 LO 4. 3 CHIEF COMPLAINTS 4- 10 LO 4. 3 Chief Complaints • Chief Complaint – Issue that prompted patient to seek care – Subjective – Should be documented in patient’s words as quote 4- 11 LO 4. 4... women 4- 14 LO 4. 4 Vitals (Vital Signs) • Vitals graphs – Blood pressure – Height – Weight – BMI • Includes children’s growth charts 4- 15 LO 4. 5 EXAM (PHYSICAL ASSESSMENT) 4- 16 LO 4. 5 Exam (Physical