Lecture Nursing documentation using electronic health records: Chapter 9 - Byron R. Hamilton, Mary Harper, Paul Moore

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.

9-1 Chapter Routine Documentation McGraw­Hill © 2012 The McGraw­Hill Companies, Inc. All rights reserved 9-2 Chapter Content LO 9.1 LO 9.2 LO 9.3 LO 9.4 LO 9.5 ToDos and Reminders Internal Messages Immunization Record Patient Instructions Draw Program 9-3 LO 9.1 TODOS AND REMINDERS 9-4 LO 9.1 ToDos and Reminders • Electronic task list – Personal use – May be sent to others – May be scheduled to send at later date 9-5 LO 9.2 INTERNAL MESSAGES 9-6 LO 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 – E-mail • Processed centrally 9-7 LO 9.3 IMMUNIZATION RECORD 9-8 LO 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 9-9 LO 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 9-10 LO 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) 9-11 LO 9.4 PATIENT INSTRUCTIONS 9-12 LO 9.4 Patient Instructions • Written instructions augment verbal education • Reputable patient education Websites: – Food and Drug Administration Website ( http://www.fda.gov/Drugs/DrugSafety/PostmarketDrug ) – National Institutes of Health Medline Plus Webpage (http:// www.nlm.nih.gov/medlineplus/medlineplus.html ) 9-13 LO 9.4 Patient Instructions • Nurse ultimately responsible – Content of patient instructions – Evaluation and documentation of patient understanding 9-14 LO 9.5 DRAW PROGRAM 9-15 LO 9.5 Draw Program • Photographs and drawings – Supplement narrative descriptions • Wound stages • Effectiveness of treatment • Injuries/conditions present on admission 9-16 LO 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) 9-17 LO 9.5 Draw Program • Photos useful with the following POA conditions – Pressure ulcers – Injuries due to falls – Vascular catheter-associated infections .. . 9- 2 Chapter Content LO 9. 1 LO 9. 2 LO 9. 3 LO 9. 4 LO 9. 5 ToDos and Reminders Internal Messages Immunization Record Patient Instructions Draw Program 9- 3 LO 9. 1 TODOS AND REMINDERS 9- 4 LO 9. 1... • Electronic task list – Personal use – May be sent to others – May be scheduled to send at later date 9- 5 LO 9. 2 INTERNAL MESSAGES 9- 6 LO 9. 2 Internal Messages • Internal Messages – Intra- and... Eliminates time spent looking for co-worker • Not saved/stored – E-mail • Processed centrally 9- 7 LO 9. 3 IMMUNIZATION RECORD 9- 8 LO 9. 3 Immunization Record • Immunization history – Important for