11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

11-2 Chapter 11 Content LO 11.1 Teaching (Patient Education) LO 11.2 Evaluation LO 11.3 Reassessment LO 11.4 F/U-REM (Follow-up Reminders/ToDo List)

11-3 LO 11.1 TEACHING (PATIENT EDUCATION)

11-4 LO 11.1 Teaching (Patient Education) Patient education – Key intervention for nursing – SpringCharts has specific area focused on documentation of instruction Intervention component of SOAPIER

11-5 LO 11.2 EVALUATION

11-6 LO 11.2 Evaluation Evaluation – Patient progress toward meeting outcomes must be evaluated routinely Determine if nursing interventions are effective Determine if outcomes have been met or if the plan of care requires revision

11-7 LO 11.3 REASSESSMENT

11-8 LO 11.3 Reassessment Reassessment – Response to intervention Analgesic Diuretics – Post-procedure Surgery Heart catheterization

11-9 LO 11.4 F/U-REM (FOLLOW-UP REMINDERS/TODO LIST)

11-10 LO 11.4 F/U-REM (Follow-up Reminders/ToDo List) Follow-up reminders – Allows nurse to set reminders for follow-up care – Useful for discharge disposition