Y khoa, y dược - Chapter 7: Ambulatory healthcare

Chapter 7Ambulatory Healthcare© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 7 ContentLO 7.1 The Ambulatory NurseLO 7.2 Building an Office Visit NoteLO 7.3 Modifying the Office Visit NoteLO 7.4 Creating an AddendumLO 7.1 THE AMBULATORY NURSELO 7.1 The Ambulatory NurseAmbulatory nursingIncreased demand due to movement of patient care to outpatient settingEpisodic care < 24 hoursHighly interdisciplinaryLO 7.1 The Ambulatory NurseUnique set of nursing skillsAssessmentHealth promotionHealth maintenancePatient educationPatient advocacyCollaborationFinancial aspects of patient careAmerican Association of Ambulatory Care Nurses (AAACN)LO 7.1 The Ambulatory NurseNurse practitionersAdvanced practice nursesLicensed independent practitionersAdvanced educationHolistic practiceScope of practice regulated by individual statesAssigning medical dxPrescribing medications and treatmentsLO 7.1 The Ambulatory NurseResearch findings:Nurse practitionersProduce outcomes comparable to physiciansProvide cost-effective careRank higher than physicians in patient satisfactionLO 7.2 BUILDING AN OFFICE VISIT NOTELO 7.2 Building an Office Visit NoteSubjective Components of Office VisitChief complaintPrimary reason patient seeks careBest documented as patient quotePresent illnessOnsetDurationSeverityAggravating and alleviating factorsReview of systemsSpecific data about each body systemLO 7.2 Building an Office Visit NoteSubjective Components of Office Visit (cont.)Health HistoryObtained on initial visitReviewed and updated with subsequent visitsPromotes accurate diagnosisLO 7.2 Building an Office Visit NoteObjective components of Office VisitVital signsExaminationLO 7.2 Building an Office Visit NoteOther components of Office VisitMedical diagnosisMedicationsEpocrates WebsiteDrug interaction/allergy alertsSureScripts Web-based e-prescribing clearinghouseTestsProceduresOther treatmentFollow-up/RemindersLO 7.3 MODIFYING THE OFFICE VISIT NOTELO 7.3 Modifying the Office Visit NoteModification of OV noteAllows various disciplines to document during one encounterEntries initialed Permanently signed and locked at end of encounterLO 7.4 CREATING AN ADDENDUMLO 7.4 Creating an AddendumOnce permanently signed and locked – no changed to office visitAddendumAllows for entry of information after the factClarificationAddition of inadvertently omitted information