Lecture Nursing documentation using electronic health records: Chapter 11 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 11 - Nurse note documentation, level 3. After completing Chapter 11, the students will be able to: Carry out documentation of patient education and response, identify patient response to interventions, carry out documentation re-assessment/revision of goals, use Todo/Reminders within the Nurse Note.

11-1 Chapter 11 Nurse Note Documentation Level McGraw­Hill © 2012 The McGraw­Hill Companies, Inc. All rights reserved 11-2 Chapter 11 Content LO 11.1 Teaching (Patient Education) LO 11.2 Evaluation LO 11.3 Reassessment LO 11.4 F/U-REM (Follow-up Reminders/ToDo List) LO 11.1 TEACHING (PATIENT EDUCATION) 11-3 11-4 LO 11.1 Teaching (Patient Education) • Patient education – Key intervention for nursing – SpringCharts has specific area focused on documentation of instruction • Intervention component of SOAPIER LO 11.2 EVALUATION 11-5 11-6 LO 11.2 Evaluation • Evaluation – Patient progress toward meeting outcomes must be evaluated routinely • Determine if nursing interventions are effective • Determine if outcomes have been met or if the plan of care requires revision LO 11.3 REASSESSMENT 11-7 11-8 LO 11.3 Reassessment • Reassessment – Response to intervention • Analgesic • Diuretics – Post-procedure • Surgery • Heart catheterization LO 11.4 F/U-REM (FOLLOW-UP REMINDERS/TODO LIST) 11-9 11-10 LO 11.4 F/U-REM (Follow-up Reminders/ToDo List) • Follow-up reminders – Allows nurse to set reminders for follow-up care – Useful for discharge disposition .. .1 1- 2 Chapter 11 Content LO 11. 1 Teaching (Patient Education) LO 11. 2 Evaluation LO 11. 3 Reassessment LO 11. 4 F/U-REM (Follow-up Reminders/ToDo List) LO 11. 1 TEACHING (PATIENT EDUCATION) 1 1- 3... LO 11. 3 REASSESSMENT 1 1- 7 1 1- 8 LO 11. 3 Reassessment • Reassessment – Response to intervention • Analgesic • Diuretics – Post-procedure • Surgery • Heart catheterization LO 11. 4 F/U-REM (FOLLOW-UP... F/U-REM (FOLLOW-UP REMINDERS/TODO LIST) 1 1- 9 1 1- 10 LO 11. 4 F/U-REM (Follow-up Reminders/ToDo List) • Follow-up reminders – Allows nurse to set reminders for follow-up care – Useful for discharge disposition