Lecture Nursing documentation using electronic health records: Chapter 11 - Byron R. Hamilton, Mary Harper, Paul Moore

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Chapter 11
Nurse Note Documentation
Level 3

McGraw­Hill

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


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Chapter 11 Content
LO 11.1 Teaching (Patient Education)
LO 11.2 Evaluation
LO 11.3 Reassessment
LO 11.4 F/U-REM (Follow-up
Reminders/ToDo List)


LO 11.1 TEACHING (PATIENT
EDUCATION)

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LO 11.1 Teaching (Patient
Education)

• Patient education
– Key intervention for nursing
– SpringCharts has specific area focused on
documentation of instruction
• Intervention component of SOAPIER


LO 11.2 EVALUATION

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LO 11.2 Evaluation
• Evaluation
– Patient progress toward meeting outcomes
must be evaluated routinely
• Determine if nursing interventions are effective
• Determine if outcomes have been met or if the
plan of care requires revision


LO 11.3 REASSESSMENT

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LO 11.3 Reassessment
• Reassessment
– Response to intervention
• Analgesic
• Diuretics

– Post-procedure
• Surgery
• Heart catheterization


LO 11.4 F/U-REM (FOLLOW-UP
REMINDERS/TODO LIST)

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LO 11.4 F/U-REM (Follow-up
Reminders/ToDo List)
• Follow-up reminders
– Allows nurse to set reminders for follow-up
care
– Useful for discharge disposition