TAILIEUCHUNG - Lecture Nursing documentation using electronic health records: Chapter 6 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 4 - Nurse note documentation, level 2. After completing Chapter 6, the students will be able to: Use NANDA-International (NANDA-I) approved nursing diagnoses to reflect patient needs, identify patient specific goals using Nursing Outcomes Classification (NOC), identify and document nursing interventions using Nursing Intervention Classification (NIC), carry out documentation of medication administration, carry out documentation of intake and output (I&O). | Chapter 6 Nurse Note Documentation Level 2 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 6 Content LO Dx (Nursing Diagnosis) LO NOC (Nursing Outcomes) LO NIC (Nursing Interventions) LO MAR (Medication Administration Record) LO I&O (Intake and Output) LO DX (NURSING DIAGNOSIS) LO Dx (Nursing Diagnosis) Standardized language Mechanism for communication Reflects nursing practice Facilitates use of technology Allows comparison of nursing activities Used in research Promotes quality patient care 12 systems recognized by ANA LO Dx (Nursing Diagnosis) NANDA-I nursing dx, NOC, NIC Widely recognized Research based Comprehensive LO Dx (Nursing Diagnosis) Nursing process Assessment/diagnosis Planning Intervention Evaluation LO Dx (Nursing Diagnosis) Assessment First step in nursing process Subjective data Report of patient and/or family Objective data Observations of nurse Observation Auscultation Palpation Smell LO .

• Y khoa - Dược
• Nursing documentation
• Electronic health records
• Nurse note documentation
• Fundamental documentation
• Nursing diagnosis
• Nursing outcomes
• Nursing practice
• Medication administration
• Patient education
• Nursing diagnoses
• Nursing interventions
• Essential documentation
• SpringCharts features
• Routine documentation
• Internal messages
• EHR history
• Development of EHR standards
• Chief complaints
• Nurse note components
• Recording vital signs
• Documenting telephone calls
• Ambulatory healthcare
• Ambulatory nurse
• Diagnostic tests
• Nursing Services
• Sensitive Healthcare
• Newcomer Immigrants
• Health Nursing
• Healing Energy
• Professional Communication
• PEG Nutrition
• Documenting Behaviour
• Behavioural Management
• Effective Design
• Incident Reports