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Lecture Nursing documentation using electronic health records: Chapter 9 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 9 - Routine documentation. After completing Chapter 9, the students will be able to: Use the ToDo List feature, use internal messages, carry out accessing and completing the patient’s immunization record, carry out creating and distributing a patient instruction sheet, use the draw program to develop illustrations to enhance documentation. | Chapter 9 Routine Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 9 Content LO 9.1 ToDos and Reminders LO 9.2 Internal Messages LO 9.3 Immunization Record LO 9.4 Patient Instructions LO 9.5 Draw Program LO 9.1 TODOS AND REMINDERS LO 9.1 ToDos and Reminders Electronic task list Personal use May be sent to others May be scheduled to send at later date LO 9.2 INTERNAL MESSAGES LO 9.2 Internal Messages Internal Messages Intra- and interoffice mail function May be patient related or non-patient related Patient related saved in patient’s chart Non-patient related - archived Urgent messages Discreet method of communication Eliminates time spent looking for co-worker Not saved/stored E-mail Processed centrally LO 9.3 IMMUNIZATION RECORD LO 9.3 Immunization Record Immunization history Important for both adult and pediatric patients Inpatient and outpatient setting Inpatient setting Adults must be offered influenza and pneumococcal vaccines if . | Chapter 9 Routine Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 9 Content LO 9.1 ToDos and Reminders LO 9.2 Internal Messages LO 9.3 Immunization Record LO 9.4 Patient Instructions LO 9.5 Draw Program LO 9.1 TODOS AND REMINDERS LO 9.1 ToDos and Reminders Electronic task list Personal use May be sent to others May be scheduled to send at later date LO 9.2 INTERNAL MESSAGES LO 9.2 Internal Messages Internal Messages Intra- and interoffice mail function May be patient related or non-patient related Patient related saved in patient’s chart Non-patient related - archived Urgent messages Discreet method of communication Eliminates time spent looking for co-worker Not saved/stored E-mail Processed centrally LO 9.3 IMMUNIZATION RECORD LO 9.3 Immunization Record Immunization history Important for both adult and pediatric patients Inpatient and outpatient setting Inpatient setting Adults must be offered influenza and pneumococcal vaccines if meet certain criteria Healthy People 2020 Goal to increase the numbers of adults over 65 who have annual influenza vaccines and who are immunized once with the pneumococcal vaccine LO 9.3 Immunization Record Vaccine Information Statements (VIS) Developed by the Centers for Disease Control and Prevention (CDC) Explains the risks and benefits of vaccines Must be given to a patient or guardian before administration of certain immunizations LO 9.3 Immunization Record Required documentation for vaccines Date of edition of the VIS Date the VIS is provided to the patient or legal representative Date of administration Manufacturer Lot number Name, title, and address of the individual administering the vaccine (may be kept in office file) LO 9.4 PATIENT INSTRUCTIONS LO 9.4 Patient Instructions Written instructions augment verbal education Reputable patient education Websites: Food and Drug Administration Website .