TAILIEUCHUNG - Lecture Nursing documentation using electronic health records: Chapter 9 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 9 - Routine documentation. After completing Chapter 9, the students will be able to: Use the ToDo List feature, use internal messages, carry out accessing and completing the patient’s immunization record, carry out creating and distributing a patient instruction sheet, use the draw program to develop illustrations to enhance documentation. | Chapter 9 Routine Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 9 Content LO ToDos and Reminders LO Internal Messages LO Immunization Record LO Patient Instructions LO Draw Program LO TODOS AND REMINDERS LO ToDos and Reminders Electronic task list Personal use May be sent to others May be scheduled to send at later date LO INTERNAL MESSAGES LO Internal Messages Internal Messages Intra- and interoffice mail function May be patient related or non-patient related Patient related saved in patient’s chart Non-patient related - archived Urgent messages Discreet method of communication Eliminates time spent looking for co-worker Not saved/stored E-mail Processed centrally LO IMMUNIZATION RECORD LO Immunization Record Immunization history Important for both adult and pediatric patients Inpatient and outpatient setting Inpatient setting Adults must be offered influenza and pneumococcal vaccines if .

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• Nursing documentation
• Electronic health records
• Nurse note documentation
• Fundamental documentation
• Routine documentation
• Internal messages
• Nursing diagnosis
• Nursing outcomes
• Nursing practice
• Medication administration
• Patient education
• Nursing diagnoses
• Nursing interventions
• Essential documentation
• SpringCharts features
• 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