TAILIEUCHUNG - Lecture Nursing documentation using electronic health records: Chapter 7 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 7 - Ambulatory healthcare. After completing Chapter 7, the student will be able to: Describe the role of an ambulatory nurse, use SpringCharts to create an office visit note, use SpringCharts to modify an office visit note, carryout preparing an addendum to the office visit note. | Chapter 7 Ambulatory Healthcare © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 7 Content LO The Ambulatory Nurse LO Building an Office Visit Note LO Modifying the Office Visit Note LO Creating an Addendum LO THE AMBULATORY NURSE LO The Ambulatory Nurse Ambulatory nursing Increased demand due to movement of patient care to outpatient setting Episodic care < 24 hours Highly interdisciplinary LO The Ambulatory Nurse Unique set of nursing skills Assessment Health promotion Health maintenance Patient education Patient advocacy Collaboration Financial aspects of patient care American Association of Ambulatory Care Nurses (AAACN) LO The Ambulatory Nurse Nurse practitioners Advanced practice nurses Licensed independent practitioners Advanced education Holistic practice Scope of practice regulated by individual states Assigning medical dx Prescribing medications and treatments LO The Ambulatory Nurse Research findings: Nurse

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• Nursing documentation
• Electronic health records
• Nurse note documentation
• Fundamental documentation
• Ambulatory healthcare
• Ambulatory nurse
• 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
• Diagnostic tests
• Nursing Services
• Sensitive Healthcare
• Newcomer Immigrants
• Health Nursing
• Healing Energy
• Professional Communication
• PEG Nutrition
• Documenting Behaviour
• Behavioural Management
• Effective Design
• Incident Reports