Lecture Nursing documentation using electronic health records: Chapter 9 - Byron R. Hamilton, Mary Harper, Paul Moore

9-1

Chapter 9
Routine Documentation

McGraw­Hill

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


9-2

Chapter 9 Content
LO 9.1
LO 9.2
LO 9.3
LO 9.4
LO 9.5

ToDos and Reminders
Internal Messages
Immunization Record
Patient Instructions
Draw Program


9-3

LO 9.1 TODOS AND
REMINDERS

9-4

LO 9.1 ToDos and Reminders
• Electronic task list
– Personal use
– May be sent to others
– May be scheduled to send at later date


9-5

LO 9.2 INTERNAL MESSAGES


9-6

LO 9.2 Internal Messages
• Internal Messages
– Intra- and interoffice mail function
– May be patient related or non-patient related
• Patient related saved in patient’s chart
• Non-patient related - archived

– Urgent messages
• Discreet method of communication
• Eliminates time spent looking for co-worker
• Not saved/stored

– E-mail

• Processed centrally


9-7

LO 9.3 IMMUNIZATION
RECORD


9-8

LO 9.3 Immunization Record
• Immunization history
– Important for both adult and pediatric patients
– Inpatient and outpatient setting

• Inpatient setting
– Adults must be offered influenza and
pneumococcal vaccines if meet certain criteria

• Healthy People 2020
– Goal to increase the numbers of adults over 65
who have annual influenza vaccines and who are
immunized once with the pneumococcal vaccine


9-9

LO 9.3 Immunization Record
• Vaccine Information Statements (VIS)

– Developed by the Centers for Disease Control
and Prevention (CDC)
– Explains the risks and benefits of vaccines
– Must be given to a patient or guardian before
administration of certain immunizations


9-10

LO 9.3 Immunization Record
• Required documentation for vaccines
– Date of edition of the VIS
– Date the VIS is provided to the patient or legal
representative
– Date of administration
– Manufacturer
– Lot number
– Name, title, and address of the individual
administering the vaccine (may be kept in
office file)


9-11

LO 9.4 PATIENT
INSTRUCTIONS


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LO 9.4 Patient Instructions
• Written instructions augment verbal
education
• Reputable patient education Websites:

– Food and Drug Administration Website (
/>)
– National Institutes of Health Medline Plus
Webpage (http://
www.nlm.nih.gov/medlineplus/medlineplus.html )


9-13

LO 9.4 Patient Instructions
• Nurse ultimately responsible
– Content of patient instructions
– Evaluation and documentation of patient
understanding


9-14

LO 9.5 DRAW PROGRAM


9-15

LO 9.5 Draw Program
• Photographs and drawings

– Supplement narrative descriptions
• Wound stages
• Effectiveness of treatment
• Injuries/conditions present on admission


9-16

LO 9.5 Draw Program
• Deficit Reduction Act of 2005
– Identification of certain conditions
• Increase cost of care
• Preventable through use of EBP

– CMS (2008)
• Withhold payment for these hospital acquired
conditions (HAC)
• Increasingly important to document if present on
admission (POA)


9-17

LO 9.5 Draw Program
• Photos useful with the following POA
conditions
– Pressure ulcers
– Injuries due to falls
– Vascular catheter-associated infections