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Chapter 11

Nurse Note DocumentationLevel 3

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

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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)

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LO 11.1 TEACHING (PATIENT EDUCATION)

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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

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LO 11.2 EVALUATION

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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

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LO 11.3 REASSESSMENT

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LO 11.3 Reassessment

• Reassessment– Response to intervention• Analgesic• Diuretics

– Post-procedure• Surgery• Heart catheterization

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LO 11.4 F/U-REM (FOLLOW-UP REMINDERS/TODO LIST)

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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