TAILIEUCHUNG - Lecture Nursing documentation using electronic health records: Chapter 4 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 4 - Nurse note documentation, level 1. After completing Chapter 4, the students will be able to: Describe the components of a nurse note, carry out documentation of a nurse note, use chief complaints, carry out documentation of vitals (vital signs), carry out documentation of an exam (assessment). | Chapter 4 Nurse Note Documentation Level 1 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 4 Content LO Nurse Note Components LO Documenting a Nurse Note – Level 1 LO Chief Complaints LO Vitals (Vital Signs) LO Exam (Physical Assessment) LO NURSE NOTE COMPONENTS LO Nurse Note Components Nursing Documentation Facilitated by Charting by Exception (CBE) EHRs provide for rapid access to patient information Nurse Note Area of chart for nursing documentation LO Nurse Note Components SOAPIER S = Subjective O = Objective A = Assessment P = Plan I = Intervention E = Evaluation R = Revision/resolution LO DOCUMENTING A NURSE NOTE LO Documenting a Nurse Note Components of SpringChart Nurse Note CC (Chief Complaint), Vitals, Exam (Physical Assessment) Dx (NANDA-I/Diagnosis) NOC (Nursing Outcomes Classification) NIC (Nursing Interventions Classification) Test (Tests) Proc (Procedures) Teaching Evaluation Reassess (Reassessment)

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• Nursing documentation
• Electronic health records
• Nurse note documentation
• Fundamental documentation
• Chief complaints
• Nurse note components
• 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
• 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