Lecture Nursing documentation using electronic health records: Chapter 7 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 7 - Ambulatory healthcare. After completing Chapter 7, the student will be able to: Describe the role of an ambulatory nurse, use SpringCharts to create an office visit note, use SpringCharts to modify an office visit note, carryout preparing an addendum to the office visit note.

7-1 Chapter Ambulatory Healthcare McGraw­Hill © 2012 The McGraw­Hill Companies, Inc. All rights reserved 7-2 Chapter Content LO 7.1 LO 7.2 LO 7.3 LO 7.4 The Ambulatory Nurse Building an Office Visit Note Modifying the Office Visit Note Creating an Addendum 7-3 LO 7.1 THE AMBULATORY NURSE 7-4 LO 7.1 The Ambulatory Nurse • Ambulatory nursing – Increased demand due to movement of patient care to outpatient setting – Episodic care < 24 hours – Highly interdisciplinary 7-5 LO 7.1 The Ambulatory Nurse • Unique set of nursing skills – – – – – – – Assessment Health promotion Health maintenance Patient education Patient advocacy Collaboration Financial aspects of patient care • American Association of Ambulatory Care Nurses (AAACN) 7-6 LO 7.1 The Ambulatory Nurse • Nurse practitioners – Advanced practice nurses – Licensed independent practitioners – Advanced education – Holistic practice – Scope of practice regulated by individual states • Assigning medical dx • Prescribing medications and treatments 7-7 LO 7.1 The Ambulatory Nurse • Research findings: – Nurse practitioners • Produce outcomes comparable to physicians • Provide cost-effective care • Rank higher than physicians in patient satisfaction 7-8 LO 7.2 BUILDING AN OFFICE VISIT NOTE 7-9 LO 7.2 Building an Office Visit Note • Subjective Components of Office Visit – Chief complaint • Primary reason patient seeks care • Best documented as patient quote – Present illness • • • • Onset Duration Severity Aggravating and alleviating factors – Review of systems • Specific data about each body system 7-10 LO 7.2 Building an Office Visit Note • Subjective Components of Office Visit (cont.) – Health History • Obtained on initial visit • Reviewed and updated with subsequent visits • Promotes accurate diagnosis 7-11 LO 7.2 Building an Office Visit Note • Objective components of Office Visit – Vital signs – Examination 7-12 LO 7.2 Building an Office Visit Note • Other components of Office Visit – Medical diagnosis – Medications • Epocrates Website • Drug interaction/allergy alerts • SureScripts Web-based e-prescribing clearinghouse – – – – Tests Procedures Other treatment Follow-up/Reminders 7-13 LO 7.3 MODIFYING THE OFFICE VISIT NOTE 7-14 LO 7.3 Modifying the Office Visit Note • Modification of OV note – Allows various disciplines to document during one encounter – Entries initialed – Permanently signed and locked at end of encounter 7-15 LO 7.4 CREATING AN ADDENDUM 7-16 LO 7.4 Creating an Addendum • Once permanently signed and locked – no changed to office visit • Addendum – Allows for entry of information after the fact • Clarification • Addition of inadvertently omitted information .. . 7- 2 Chapter Content LO 7. 1 LO 7. 2 LO 7. 3 LO 7. 4 The Ambulatory Nurse Building an Office Visit Note Modifying the Office Visit Note Creating an Addendum 7- 3 LO 7. 1 THE AMBULATORY NURSE 7- 4... alerts • SureScripts Web-based e-prescribing clearinghouse – – – – Tests Procedures Other treatment Follow-up/Reminders 7- 13 LO 7. 3 MODIFYING THE OFFICE VISIT NOTE 7- 14 LO 7. 3 Modifying the Office... in patient satisfaction 7- 8 LO 7. 2 BUILDING AN OFFICE VISIT NOTE 7- 9 LO 7. 2 Building an Office Visit Note • Subjective Components of Office Visit – Chief complaint • Primary reason patient seeks