5-1 Chapter 5 Fundamental Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

5-2 Chapter 5 Content LO 5.1 Recording vital signs LO 5.2 Documenting telephone calls LO 5.3 Creating a letter to a patient or about a patient LO 5.4 Creating a letter unrelated to a patient LO 5.5 Sending a test report to a patient LO 5.6 Creating an excuse note and order form for a patient LO 5.7 Using practice guidelines LO 5.8 Using My Websites LO 5.9 Using the calculator utilities

5-3 LO 5.1 RECORDING VITAL SIGNS © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

5-4 LO 5.1 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

5-5 LO 5.2 DOCUMENTING TELEPHONE CALLS

5-6 LO 5.2 Documenting Telephone Calls Phone calls requiring documentation – To patient Education Follow-up post procedure Communicate testing/appointment details – To other healthcare providers Prescriptions Change in condition Diagnostic testing results Clarification of orders

5-7 LO 5.2 Documenting Telephone Calls Privacy considerations – Must not release private health information without consent – Follow policy for giving information Documentation requirements – Who – When – What – Response

5-8 LO 5.3 CREATING A LETTER TO A PATIENT OR ABOUT A PATIENT

5-9 LO 5.3 Creating a Letter Letter creation – Rarely done by nurses in inpatient setting – Outpatient setting Inform patient of testing, appointments Report consultation from one provider to another

5-10 LO 5.4 CREATING A LETTER UNRELATED TO A PATIENT

5-11 LO 5.4 Creating Letter Unrelated to a Patient Rarely done by nurses Hospitals, attorneys, accountants

5-12 LO 5.5 SENDING A TEST REPORT TO A PATIENT

5-13 LO 5.5 Sending a Test Report to a Patient Tests reports created for patients Post or Contain: – Test description – Test result – Text can be added that identifies problem areas and recommendations

5-14 LO 5.5 Sending a Test Report to a Patient Privacy concerns: – Transmitting private health information via risks disclosure to unauthorized individuals Travels over the internet May be accidentally sent to the wrong address Nurses should adhere to facility policy to protect themselves against liability

5-15 LO 5.6 CREATING AN EXCUSE NOTE AND ORDER FORM FOR A PATIENT

5-16 LO 5.6 Creating an Excuse note and Order Form for a Patient Excuses – Time missed due to illness – Work – School Test orders – Future date – Written physicians order required

5-17 LO 5.7 USING PRACTICE GUIDELINES

5-18 LO 5.7 Using Practice Guidelines Practice guidelines – Statements used to direct care that indicate evidence-based diagnosis and treatment for clinical conditions – Best practice/evidence-based practice – Accessible from National Guideline Clearinghouse online – May be attached to Nurse Note for easy accessibility

5-19 LO 5.8 USING MY WEBSITES

5-20 LO 5.8 Using My Websites My Websites – Provides shortcut to frequently used Websites – User based – May include patient education Websites – Nursing guidelines Joanna Briggs Institute Best Practice Series: How to Try This Series

5-21 LO 5.9 USING THE CALCULATOR UTILITIES

5-22 LO 5.9 Using the Calculator Utilities Three types – Conversion Imperial to metric Metric to imperial – Pregnancy Estimated Date of Delivery (EDD) Input Last Monthly Period (LMP) Calculates fetal age and EDD – Simple Routine mathematical calculations