TAILIEUCHUNG - Lecture Nursing documentation using electronic health records: Chapter 12 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 12 - Advanced EHR functionality. After completing Chapter 12, the students will be able to: Use EHR to order diagnostic tests, carry out a chart evaluation, use a new note to create an addendum to a nurse note, carry out printing a nurse note, carry out exporting and printing elements of a patient’s chart. | Chapter 12 Advanced EHR Functionality © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 12 Content LO Diagnostic Tests LO Chart Evaluations LO Addenda to a Nurse Note LO Printing a Nurse Note LO Exporting and Printing the Chart LO DIAGNOSTIC TESTS LO Diagnostic Tests Processing diagnostic tests Provider orders test If Computerized Physician Order Entry (CPOE) not in use, personnel submit order to appropriate department Imaging Lab Diagnostic department performs test Results entered into EHR Results available to nurse/provider LO Diagnostic Tests Communication of diagnostic test results Most EHRs have alerts for abnormal results Primary provider must be notified of most abnormal results Nursing judgment required Nurse must know underlying etiology and patient trends LO Diagnostic Tests Critical tests Delineated by facility Requires that provider notified of results even if normal Critical results Delineated by

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