12-1 Chapter 12 Advanced EHR Functionality © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.

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Chapter 12

Advanced EHR Functionality

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

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Chapter 12 Content

LO 12.1 Diagnostic TestsLO 12.2 Chart EvaluationsLO 12.3 Addenda to a Nurse NoteLO 12.4 Printing a Nurse NoteLO 12.5 Exporting and Printing the Chart

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LO 12.1 DIAGNOSTIC TESTS

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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

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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

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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

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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

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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

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LO 12.2 CHART EVALUATIONS

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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

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LO 12.2 Chart Evaluations

• Use of guideline reminders– Patient has right to refuse• Document refusal

– Provider uses clinical judgment for recommendations

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LO 12.3 ADDENDA TO A NURSE NOTE

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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

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LO 12.4 PRINTING A NURSE NOTE

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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

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LO 12.5 EXPORTING AND PRINTING THE CHART

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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

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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