Lecture Nursing documentation using electronic health records: Chapter 4 - Byron R. Hamilton, Mary Harper, Paul Moore

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Chapter 4
Nurse Note Documentation
Level 1

McGraw­Hill

© 2012 The McGraw­Hill Companies, Inc. All rights reserved.


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Chapter 4 Content
LO 4.1 Nurse Note Components
LO 4.2 Documenting a Nurse Note – Level 1
LO 4.3 Chief Complaints
LO 4.4 Vitals (Vital Signs)
LO 4.5 Exam (Physical Assessment)


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LO 4.1 NURSE NOTE
COMPONENTS


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LO 4.1 Nurse Note Components
• Nursing Documentation

– Facilitated by Charting by Exception (CBE)
– EHRs provide for rapid access to patient
information

• Nurse Note
– Area of chart for nursing documentation


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LO 4.1 Nurse Note Components
• SOAPIER
S = Subjective
O = Objective
A = Assessment
P = Plan
I = Intervention
E = Evaluation
R = Revision/resolution


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LO 4.2 DOCUMENTING A NURSE
NOTE


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LO 4.2 Documenting a Nurse

Note
• Components of SpringChart Nurse Note
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–
–
–
–
–

CC (Chief Complaint),
Vitals, Exam (Physical Assessment)
Dx (NANDA-I/Diagnosis)
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Test (Tests)
Proc (Procedures)
Teaching
Evaluation
Reassess (Reassessment)


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LO 4.2 Documenting a Nurse
Note
• Documentation methods

– Pop-up text
– Copy previous notes
– Type


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LO 4.3 CHIEF COMPLAINTS


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LO 4.3 Chief Complaints
• Chief Complaint
– Issue that prompted patient to seek care
– Subjective
– Should be documented in patient’s words as
quote


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LO 4.4 VITALS (VITAL SIGNS)


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LO 4.4 Vitals (Vital Signs)
• Traditional vital signs
–

–
–
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Temperature
Blood pressure
Pulse
Respirations

• Other measurements included by
SpringCharts
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–
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Height
Weight
Body mass index (BMI)
Body fat percentage


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LO 4.4 Vitals (Vital Signs)
• Vitals
– Objective measurements
– May add three additional measurements such
as:
• Pulse oximeter

• Pain scale
• Height of fundus in pregnant women


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LO 4.4 Vitals (Vital Signs)
• Vitals graphs
– Blood pressure
– Height
– Weight
– BMI
• Includes children’s growth charts


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LO 4.5 EXAM (PHYSICAL
ASSESSMENT)


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LO 4.5 Exam (Physical
Assessment)
• Physical assessment
– Charting by Exception (CBE)
• May indicate normal systems – must know facility
definition of “normal”
• Abnormal findings require additional detail

• Sign and Lock
– Upon completion of documentation in Nurse
Note