Y khoa, y dược - Chapter 9: Routine documentation

Chapter 9Routine Documentation© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 9 ContentLO 9.1 ToDos and RemindersLO 9.2 Internal MessagesLO 9.3 Immunization RecordLO 9.4 Patient InstructionsLO 9.5 Draw ProgramLO 9.1 TODOS AND REMINDERSLO 9.1 ToDos and RemindersElectronic task listPersonal useMay be sent to othersMay be scheduled to send at later date LO 9.2 INTERNAL MESSAGESLO 9.2 Internal MessagesInternal MessagesIntra- and interoffice mail functionMay be patient related or non-patient relatedPatient related saved in patient’s chartNon-patient related - archivedUrgent messagesDiscreet method of communicationEliminates time spent looking for co-workerNot saved/storedE-mailProcessed centrallyLO 9.3 IMMUNIZATION RECORDLO 9.3 Immunization RecordImmunization historyImportant for both adult and pediatric patientsInpatient and outpatient settingInpatient settingAdults must be offered influenza and pneumococcal vaccines if meet certain criteriaHealthy People 2020Goal to increase the numbers of adults over 65 who have annual influenza vaccines and who are immunized once with the pneumococcal vaccineLO 9.3 Immunization RecordVaccine Information Statements (VIS)Developed by the Centers for Disease Control and Prevention (CDC)Explains the risks and benefits of vaccinesMust be given to a patient or guardian before administration of certain immunizationsLO 9.3 Immunization RecordRequired documentation for vaccinesDate of edition of the VIS Date the VIS is provided to the patient or legal representative Date of administrationManufacturer Lot numberName, title, and address of the individual administering the vaccine (may be kept in office file)LO 9.4 PATIENT INSTRUCTIONSLO 9.4 Patient InstructionsWritten instructions augment verbal educationReputable patient education Websites:Food and Drug Administration Website ( )National Institutes of Health Medline Plus Webpage ( )LO 9.4 Patient InstructionsNurse ultimately responsible Content of patient instructionsEvaluation and documentation of patient understandingLO 9.5 DRAW PROGRAMLO 9.5 Draw ProgramPhotographs and drawingsSupplement narrative descriptionsWound stagesEffectiveness of treatmentInjuries/conditions present on admissionLO 9.5 Draw ProgramDeficit Reduction Act of 2005Identification of certain conditionsIncrease cost of carePreventable through use of EBPCMS (2008)Withhold payment for these hospital acquired conditions (HAC)Increasingly important to document if present on admission (POA)LO 9.5 Draw ProgramPhotos useful with the following POA conditionsPressure ulcersInjuries due to fallsVascular catheter-associated infections