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Chapter 9

Routine Documentation

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

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Chapter 9 Content

LO 9.1 ToDos and RemindersLO 9.2 Internal MessagesLO 9.3 Immunization RecordLO 9.4 Patient InstructionsLO 9.5 Draw Program

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LO 9.1 TODOS AND REMINDERS

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LO 9.1 ToDos and Reminders

• Electronic task list– Personal use– May be sent to others– May be scheduled to send at later date

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LO 9.2 INTERNAL MESSAGES

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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

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LO 9.3 IMMUNIZATION RECORD

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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

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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

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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)

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LO 9.4 PATIENT INSTRUCTIONS

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LO 9.4 Patient Instructions

• Written instructions augment verbal education• Reputable patient education Websites:– Food and Drug Administration Website (

http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM111085 )

– National Institutes of Health Medline Plus Webpage (http://www.nlm.nih.gov/medlineplus/medlineplus.html )

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LO 9.4 Patient Instructions

• Nurse ultimately responsible – Content of patient instructions– Evaluation and documentation of patient

understanding

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LO 9.5 DRAW PROGRAM

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LO 9.5 Draw Program

• Photographs and drawings– Supplement narrative descriptions• Wound stages• Effectiveness of treatment• Injuries/conditions present on admission

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LO 9.5 Draw Program

• Deficit Reduction Act of 2005– Identification of certain conditions• Increase cost of care• Preventable through use of EBP

– CMS (2008)• Withhold payment for these hospital acquired

conditions (HAC)• Increasingly important to document if present on

admission (POA)

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LO 9.5 Draw Program

• Photos useful with the following POA conditions– Pressure ulcers– Injuries due to falls– Vascular catheter-associated infections