11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights...
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Transcript of 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights...
![Page 1: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/1.jpg)
11-1
Chapter 11
Nurse Note DocumentationLevel 3
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill
![Page 2: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/2.jpg)
11-2
Chapter 11 Content
LO 11.1 Teaching (Patient Education)LO 11.2 EvaluationLO 11.3 ReassessmentLO 11.4 F/U-REM (Follow-up Reminders/ToDo
List)
![Page 3: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/3.jpg)
11-3
LO 11.1 TEACHING (PATIENT EDUCATION)
![Page 4: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/4.jpg)
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
![Page 5: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/5.jpg)
11-5
LO 11.2 EVALUATION
![Page 6: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/6.jpg)
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
![Page 7: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/7.jpg)
11-7
LO 11.3 REASSESSMENT
![Page 8: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/8.jpg)
11-8
LO 11.3 Reassessment
• Reassessment– Response to intervention• Analgesic• Diuretics
– Post-procedure• Surgery• Heart catheterization
![Page 9: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/9.jpg)
11-9
LO 11.4 F/U-REM (FOLLOW-UP REMINDERS/TODO LIST)
![Page 10: 11-1 Chapter 11 Nurse Note Documentation Level 3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.](https://reader035.fdocuments.net/reader035/viewer/2022070305/551474ce5503462d4e8b623a/html5/thumbnails/10.jpg)
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