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

2. 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

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

4. 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. 5-5 LO 5.2 DOCUMENTING TELEPHONE CALLS

6. 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

7. 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

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

9. 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

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

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

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

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

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

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

16. 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

17. 5-17 LO 5.7 USING PRACTICE GUIDELINES

18. 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

19. 5-19 LO 5.8 USING MY WEBSITES

20. 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: http://www.joannabriggs.edu.au/ http://www.joannabriggs.edu.au/ How to Try This Series http://www.nursingcenter.com/library/static.asp?pageid=73 0390 http://www.nursingcenter.com/library/static.asp?pageid=73 0390

21. 5-21 LO 5.9 USING THE CALCULATOR UTILITIES

22. 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