TAILIEUCHUNG - Lecture Nursing documentation using electronic health records: Chapter 5 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 5 content: Recording vital signs, documenting telephone calls, creating a letter to a patient or about a patient, creating a letter unrelated to a patient, sending a test report to a patient, Creating an excuse note and order form for a patient, using practice guidelines, using “my websites”, using the calculator utilities. | Chapter 5 Fundamental Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 5 Content LO Recording vital signs LO Documenting telephone calls LO Creating a letter to a patient or about a patient LO Creating a letter unrelated to a patient LO Sending a test report to a patient LO Creating an excuse note and order form for a patient LO Using practice guidelines LO Using “My Websites” LO Using the calculator utilities LO RECORDING VITAL SIGNS © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill LO 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 LO DOCUMENTING TELEPHONE CALLS LO Documenting Telephone Calls Phone calls requiring documentation To patient Education Follow-up post procedure Communicate .

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• Nursing documentation
• Electronic health records
• Nurse note documentation
• Fundamental documentation
• Recording vital signs
• Documenting telephone calls
• 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
• 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