Y khoa, y dược - Chapter 5: Fundamental documentation

Chapter 5Fundamental Documentation© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 5 ContentLO 5.1 Recording vital signsLO 5.2 Documenting telephone callsLO 5.3 Creating a letter to a patient or about a patientLO 5.4 Creating a letter unrelated to a patientLO 5.5 Sending a test report to a patientLO 5.6 Creating an excuse note and order form for a patientLO 5.7 Using practice guidelinesLO 5.8 Using “My Websites”LO 5.9 Using the calculator utilitiesLO 5.1 RECORDING VITAL SIGNS© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillLO 5.1 Recording Vital SignsVital sign monitoringOutpatient: ongoing monitoring between visitsInpatient: frequent vital signs after procedures or with unstable patientGraphing vital signsAllows visual representation of trendsLO 5.2 DOCUMENTING TELEPHONE CALLSLO 5.2 Documenting Telephone CallsPhone calls requiring documentationTo patientEducationFollow-up post procedureCommunicate testing/appointment detailsTo other healthcare providersPrescriptionsChange in conditionDiagnostic testing resultsClarification of ordersLO 5.2 Documenting Telephone CallsPrivacy considerationsMust not release private health information without consentFollow policy for giving informationDocumentation requirementsWhoWhenWhatResponse LO 5.3 CREATING A LETTER TO A PATIENT OR ABOUT A PATIENTLO 5.3 Creating a LetterLetter creationRarely done by nurses in inpatient settingOutpatient settingInform patient of testing, appointmentsReport consultation from one provider to anotherLO 5.4 CREATING A LETTER UNRELATED TO A PATIENTLO 5.4 Creating Letter Unrelated to a PatientRarely done by nursesHospitals, attorneys, accountantsLO 5.5 SENDING A TEST REPORT TO A PATIENTLO 5.5 Sending a Test Report to a PatientTests reports created for patientsPost or e-mailContain:Test description Test resultText can be added that identifies problem areas and recommendationsLO 5.5 Sending a Test Report to a PatientPrivacy concerns:Transmitting private health information via e-mail 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 liabilityLO 5.6 CREATING AN EXCUSE NOTE AND ORDER FORM FOR A PATIENTLO 5.6 Creating an Excuse note and Order Form for a PatientExcusesTime missed due to illnessWorkSchoolTest orders Future dateWritten physician’s order requiredLO 5.7 USING PRACTICE GUIDELINESLO 5.7 Using Practice GuidelinesPractice guidelinesStatements used to direct care that indicate evidence-based diagnosis and treatment for clinical conditionsBest practice/evidence-based practiceAccessible from National Guideline Clearinghouse onlineMay be attached to Nurse Note for easy accessibilityLO 5.8 USING “MY WEBSITES”LO 5.8 Using “My Websites”My WebsitesProvides shortcut to frequently used WebsitesUser basedMay include patient education WebsitesNursing guidelinesJoanna Briggs Institute Best Practice Series: to Try This Series LO 5.9 USING THE CALCULATOR UTILITIESLO 5.9 Using the Calculator UtilitiesThree typesConversionImperial to metricMetric to imperialPregnancy Estimated Date of Delivery (EDD)Input Last Monthly Period (LMP)Calculates fetal age and EDDSimple Routine mathematical calculations