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.
5-1 Chapter Fundamental Documentation McGrawHill © 2012 The McGrawHill Companies, Inc. All rights reserved 5-2 Chapter 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 5-3 LO 5.1 RECORDING VITAL SIGNS McGrawHill © 2012 The McGrawHill Companies, Inc. All rights reserved 5-4 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 5-5 LO 5.2 DOCUMENTING TELEPHONE CALLS 5-6 LO 5.2 Documenting Telephone Calls • Phone calls requiring documentation – To patient • Education • Follow-up post procedure • Communicate testing/appointment details – To other healthcare providers • • • • Prescriptions Change in condition Diagnostic testing results Clarification of orders 5-7 LO 5.2 Documenting Telephone Calls • Privacy considerations – Must not release private health information without consent – Follow policy for giving information • Documentation requirements – Who – When – What – Response 5-8 LO 5.3 CREATING A LETTER TO A PATIENT OR ABOUT A PATIENT 5-9 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 5-10 LO 5.4 CREATING A LETTER UNRELATED TO A PATIENT 5-11 LO 5.4 Creating Letter Unrelated to a Patient • Rarely done by nurses • Hospitals, attorneys, accountants 5-12 LO 5.5 SENDING A TEST REPORT TO A PATIENT 5-13 LO 5.5 Sending a Test Report to a Patient • Tests reports created for patients • Post or e-mail • Contain: – Test description – Test result – Text can be added that identifies problem areas and recommendations 5-14 LO 5.5 Sending a Test Report to a Patient • Privacy concerns: – Transmitting private health information via email 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 5-15 LO 5.6 CREATING AN EXCUSE NOTE AND ORDER FORM FOR A PATIENT 5-16 LO 5.6 Creating an Excuse note and Order Form for a Patient • Excuses – Time missed due to illness – Work – School • Test orders – Future date – Written physician’s order required 5-17 LO 5.7 USING PRACTICE GUIDELINES 5-18 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 5-19 LO 5.8 USING “MY WEBSITES” 5-20 LO 5.8 Using “My Websites” • My Websites – – – – Provides shortcut to frequently used Websites User based May include patient education Websites Nursing guidelines • Joanna Briggs Institute Best Practice Series: http:// www.joannabriggs.edu.au/ • How to Try This Series http:// www.nursingcenter.com/library/static.asp?pageid =730390 5-21 LO 5.9 USING THE CALCULATOR UTILITIES 5-22 LO 5.9 Using the Calculator Utilities • Three types – Conversion • Imperial to metric • Metric to imperial – Pregnancy Estimated Date of Delivery (EDD) • Input Last Monthly Period (LMP) • Calculates fetal age and EDD – Simple • Routine mathematical calculations ... another 5- 10 LO 5. 4 CREATING A LETTER UNRELATED TO A PATIENT 5- 11 LO 5. 4 Creating Letter Unrelated to a Patient • Rarely done by nurses • Hospitals, attorneys, accountants 5- 12 LO 5. 5 SENDING... representation of trends 5- 5 LO 5. 2 DOCUMENTING TELEPHONE CALLS 5- 6 LO 5. 2 Documenting Telephone Calls • Phone calls requiring documentation – To patient • Education • Follow-up post procedure •... 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