5-1 Chapter 5 Fundamental Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.

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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