Lecture Nursing documentation using electronic health records: Chapter 12 - Byron R. Hamilton, Mary Harper, Paul Moore

12-1

Chapter 12
Advanced EHR Functionality

McGraw­Hill

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


12-2

Chapter 12 Content
LO 12.1
LO 12.2
LO 12.3
LO 12.4
LO 12.5

Diagnostic Tests
Chart Evaluations
Addenda to a Nurse Note
Printing a Nurse Note
Exporting and Printing the Chart


12-3

LO 12.1 DIAGNOSTIC TESTS

12-4

LO 12.1 Diagnostic Tests
• Processing diagnostic tests
– Provider orders test
– If Computerized Physician Order Entry
(CPOE) not in use, personnel submit order to
appropriate department
• Imaging
• Lab

– Diagnostic department performs test
– Results entered into EHR
– Results available to nurse/provider


12-5

LO 12.1 Diagnostic Tests
• Communication of diagnostic test results
– Most EHRs have alerts for abnormal results
– Primary provider must be notified of most
abnormal results
• Nursing judgment required
• Nurse must know underlying etiology and patient
trends


12-6

LO 12.1 Diagnostic Tests
• Critical tests
– Delineated by facility
– Requires that provider notified of results even
if normal

• Critical results
– Delineated by facility
– Grossly abnormal results that require
immediate provider notification


12-7

LO 12.1 Diagnostic Tests
• Required documentation
– Name of primary care provider notified
– Date and time notified
– Results of test reported
– Provider’s response
• No new orders
• New orders received


12-8

LO 12.1 Diagnostic Tests
• Failure to communicate lab results as
indicated
– May constitute nursing negligence

– Follow facility chain-of-command policy if
unable to reach provider


12-9

LO 12.2 CHART
EVALUATIONS


12-10

LO 12.2 Chart Evaluations
• Chart evaluations
– Provide mechanism for determining when
health promotion and disease prevention
interventions needed
• Screening tests/exams
• Immunizations

– Based on gender, age, personal and family
health history
– Improves adherence to practice guidelines


12-11

LO 12.2 Chart Evaluations
• Use of guideline reminders
– Patient has right to refuse

• Document refusal

– Provider uses clinical judgment for
recommendations


12-12

LO 12.3 ADDENDA TO A NURSE
NOTE


12-13

LO 12.3 Addenda to a Nurse
Note
• Addendum = late entry
– Used to add information omitted from original
note
– Includes information about actual date and
time of occurrence


12-14

LO 12.4 PRINTING A NURSE
NOTE


12-15

LO 12.4 Printing a Nurse Note
• Rarely required
– Nurse note may be printed when transferring
patient to another facility without EHR

• Follow facility policy for release of records


12-16

LO 12.5 EXPORTING AND
PRINTING THE CHART


12-17

LO 12.5 Exporting and Printing the
Chart
• Legal considerations
– The Medical Records Confidentiality Act of
1995
• First comprehensive federal legislation protecting
personal health information
• Requires individuals to consent to release of health
information for treatment or payment

– Individual state laws also regulate
confidentiality of health records
– In most cases, patient health records can only

be released to others with the patient’s
consent


12-18

LO 12.5 Exporting and Printing the
Chart
• Release of records
– Healthcare facilities have ‘release of records’
forms

• Privacy of records
– Federal law requires healthcare providers to
employ security measures to ensure privacy
of protected health information during
electronic transmission