7-1 Chapter 7 Ambulatory Healthcare © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

7-2 Chapter 7 Content LO 7.1 The Ambulatory Nurse LO 7.2 Building an Office Visit Note LO 7.3 Modifying the Office Visit Note LO 7.4 Creating an Addendum

7-3 LO 7.1 THE AMBULATORY NURSE

7-4 LO 7.1 The Ambulatory Nurse Ambulatory nursing – Increased demand due to movement of patient care to outpatient setting – Episodic care < 24 hours – Highly interdisciplinary

7-5 LO 7.1 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)

7-6 LO 7.1 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

7-7 LO 7.1 The Ambulatory Nurse Research findings: – Nurse practitioners Produce outcomes comparable to physicians Provide cost-effective care Rank higher than physicians in patient satisfaction

7-8 LO 7.2 BUILDING AN OFFICE VISIT NOTE

7-9 LO 7.2 Building an Office Visit Note Subjective Components of Office Visit – Chief complaint Primary reason patient seeks care Best documented as patient quote – Present illness Onset Duration Severity Aggravating and alleviating factors – Review of systems Specific data about each body system

7-10 LO 7.2 Building an Office Visit Note Subjective Components of Office Visit (cont.) – Health History Obtained on initial visit Reviewed and updated with subsequent visits Promotes accurate diagnosis

7-11 LO 7.2 Building an Office Visit Note Objective components of Office Visit – Vital signs – Examination

7-12 LO 7.2 Building an Office Visit Note Other components of Office Visit – Medical diagnosis – Medications Epocrates Website Drug interaction/allergy alerts SureScripts Web-based e-prescribing clearinghouse – Tests – Procedures – Other treatment – Follow-up/Reminders

7-13 LO 7.3 MODIFYING THE OFFICE VISIT NOTE

7-14 LO 7.3 Modifying the Office Visit Note Modification of OV note – Allows various disciplines to document during one encounter – Entries initialed – Permanently signed and locked at end of encounter

7-15 LO 7.4 CREATING AN ADDENDUM

7-16 LO 7.4 Creating an Addendum Once permanently signed and locked – no changed to office visit Addendum – Allows for entry of information after the fact Clarification Addition of inadvertently omitted information