1. 12-1 Chapter 12 Advanced EHR Functionality © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

2. 12-2 Chapter 12 Content LO 12.1 Diagnostic Tests LO 12.2 Chart Evaluations LO 12.3 Addenda to a Nurse Note LO 12.4 Printing a Nurse Note LO 12.5 Exporting and Printing the Chart

3. 12-3 LO 12.1 DIAGNOSTIC TESTS

4. 12-4 LO 12.1 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

5. 12-5 LO 12.1 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

6. 12-6 LO 12.1 Diagnostic Tests Critical tests – Delineated by facility – Requires that provider notified of results even if normal Critical results – Delineated by facility – Grossly abnormal results that require immediate provider notification

7. 12-7 LO 12.1 Diagnostic Tests Required documentation – Name of primary care provider notified – Date and time notified – Results of test reported – Providers response No new orders New orders received

8. 12-8 LO 12.1 Diagnostic Tests Failure to communicate lab results as indicated – May constitute nursing negligence – Follow facility chain-of-command policy if unable to reach provider

9. 12-9 LO 12.2 CHART EVALUATIONS

10. 12-10 LO 12.2 Chart Evaluations Chart evaluations – Provide mechanism for determining when health promotion and disease prevention interventions needed Screening tests/exams Immunizations – Based on gender, age, personal and family health history – Improves adherence to practice guidelines

11. 12-11 LO 12.2 Chart Evaluations Use of guideline reminders – Patient has right to refuse Document refusal – Provider uses clinical judgment for recommendations

12. 12-12 LO 12.3 ADDENDA TO A NURSE NOTE

13. 12-13 LO 12.3 Addenda to a Nurse Note Addendum = late entry – Used to add information omitted from original note – Includes information about actual date and time of occurrence

14. 12-14 LO 12.4 PRINTING A NURSE NOTE

15. 12-15 LO 12.4 Printing a Nurse Note Rarely required – Nurse note may be printed when transferring patient to another facility without EHR Follow facility policy for release of records

16. 12-16 LO 12.5 EXPORTING AND PRINTING THE CHART

17. 12-17 LO 12.5 Exporting and Printing the Chart Legal considerations – The Medical Records Confidentiality Act of 1995 First comprehensive federal legislation protecting personal health information Requires individuals to consent to release of health information for treatment or payment – Individual state laws also regulate confidentiality of health records – In most cases, patient health records can only be released to others with the patients consent

18. 12-18 LO 12.5 Exporting and Printing the Chart Release of records – Healthcare facilities have release of records forms Privacy of records – Federal law requires healthcare providers to employ security measures to ensure privacy of protected health information during electronic transmission