5-1 Chapter 5 Fundamental Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill
Mar 26, 2015
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Chapter 5
Fundamental Documentation
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill
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Chapter 5 Content
LO 5.1 Recording vital signsLO 5.2 Documenting telephone callsLO 5.3 Creating a letter to a patient or about a patientLO 5.4 Creating a letter unrelated to a patientLO 5.5 Sending a test report to a patientLO 5.6 Creating an excuse note and order form for a
patientLO 5.7 Using practice guidelinesLO 5.8 Using “My Websites”LO 5.9 Using the calculator utilities
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LO 5.1 RECORDING VITAL SIGNS
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill
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LO 5.1 Recording Vital Signs
• Vital sign monitoring– Outpatient: ongoing monitoring between visits– Inpatient: frequent vital signs after procedures or
with unstable patient
• Graphing vital signs– Allows visual representation of trends
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LO 5.2 DOCUMENTING TELEPHONE CALLS
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LO 5.2 Documenting Telephone Calls
• Phone calls requiring documentation– To patient• Education• Follow-up post procedure• Communicate testing/appointment details
– To other healthcare providers• Prescriptions• Change in condition• Diagnostic testing results• Clarification of orders
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LO 5.2 Documenting Telephone Calls
• Privacy considerations– Must not release private health information
without consent– Follow policy for giving information
• Documentation requirements– Who– When– What– Response
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LO 5.3 CREATING A LETTER TO A PATIENT OR ABOUT A PATIENT
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LO 5.3 Creating a Letter
• Letter creation– Rarely done by nurses in inpatient setting– Outpatient setting• Inform patient of testing, appointments• Report consultation from one provider to another
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LO 5.4 CREATING A LETTER UNRELATED TO A PATIENT
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LO 5.4 Creating Letter Unrelated to a Patient
• Rarely done by nurses• Hospitals, attorneys, accountants
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LO 5.5 SENDING A TEST REPORT TO A PATIENT
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LO 5.5 Sending a Test Report to a Patient
• Tests reports created for patients• Post or e-mail• Contain:– Test description – Test result– Text can be added that identifies problem areas
and recommendations
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LO 5.5 Sending a Test Report to a Patient
• Privacy concerns:– Transmitting private health information via e-mail
risks disclosure to unauthorized individuals • Travels over the internet • May be accidentally sent to the wrong e-mail address
• Nurses should adhere to facility policy to protect themselves against liability
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LO 5.6 CREATING AN EXCUSE NOTE AND ORDER FORM FOR A PATIENT
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LO 5.6 Creating an Excuse note and Order Form for a Patient
• Excuses– Time missed due to illness– Work– School
• Test orders – Future date– Written physician’s order required
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LO 5.7 USING PRACTICE GUIDELINES
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LO 5.7 Using Practice Guidelines
• Practice guidelines– Statements used to direct care that indicate
evidence-based diagnosis and treatment for clinical conditions
– Best practice/evidence-based practice– Accessible from National Guideline Clearinghouse
online– May be attached to Nurse Note for easy
accessibility
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LO 5.8 USING “MY WEBSITES”
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LO 5.8 Using “My Websites”
• My Websites– Provides shortcut to frequently used Websites– User based– May include patient education Websites– Nursing guidelines
• Joanna Briggs Institute Best Practice Series: http://www.joannabriggs.edu.au/
• How to Try This Series http://www.nursingcenter.com/library/static.asp?pageid=730390
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LO 5.9 USING THE CALCULATOR UTILITIES
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LO 5.9 Using the Calculator Utilities
• Three types– Conversion• Imperial to metric• Metric to imperial
– Pregnancy Estimated Date of Delivery (EDD)• Input Last Monthly Period (LMP)• Calculates fetal age and EDD
– Simple • Routine mathematical calculations