Chapter 2 - Nursing documentation overview. After completing Chapter 2, the students will be able to: Describe the role of documentation in nursing practice; identify the purposes of documentation; identify and explain different types of documentation methods; explain documentation of medication administration using an electronic Medication Administration Record (eMAR); explain the importance and relevance of nursing diagnoses, NOC, and NIC in nursing documentation.
Nurses constantly complain that they have insufficient time for proper
documentation. In many ways this is understandable. Nursing is
essentially about caring, and many aged-care facilities today are understaffed
and under-resourced. In
these circumstances it is hardly
surprising that many nurses
feel that caring comes first and
documentation comes second—that
they have time to care or time to
write, but do not have time for both.
Chapter 1 - An introduction to electronic health records. Chapter 1 content: Brief history of electronic health records (EHRs), history of standards development for the EHR and nursing’s role in their development, certification bodies for the EHR, benefits of the EHR, government involvement in the EHR, role of nursing informatics in healthcare.
Chapter 3 - Essential documentation. After completing Chapter 3, the students will be able to: Describe the basic features of SpringCharts EHR, describe the history of SpringCharts EHR, apply user preferences, carry out setting up and editing patients, use pop-up text, explain the concept of an electronic chart, use the electronic chart’s face sheet, use the SpringCharts EHR care tree.
Chapter 4 - Nurse note documentation, level 1. After completing Chapter 4, the students will be able to: Describe the components of a nurse note, carry out documentation of a nurse note, use chief complaints, carry out documentation of vitals (vital signs), carry out documentation of an exam (assessment).
Chapter 5 content: Recording vital signs, documenting telephone calls, creating a letter to a patient or about a patient, creating a letter unrelated to a patient, sending a test report to a patient, Creating an excuse note and order form for a patient, using practice guidelines, using “my websites”, using the calculator utilities.
Chapter 4 - Nurse note documentation, level 2. After completing Chapter 6, the students will be able to: Use NANDA-International (NANDA-I) approved nursing diagnoses to reflect patient needs, identify patient specific goals using Nursing Outcomes Classification (NOC), identify and document nursing interventions using Nursing Intervention Classification (NIC), carry out documentation of medication administration, carry out documentation of intake and output (I&O).
Chapter 7 - Ambulatory healthcare. After completing Chapter 7, the student will be able to: Describe the role of an ambulatory nurse, use SpringCharts to create an office visit note, use SpringCharts to modify an office visit note, carryout preparing an addendum to the office visit note.
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 10 - Patient education. Chapter 10 content: patients’ rights and nurses’ responsibilities related to education; accreditation requirements for patient education; patients’ learning needs; nursing diagnoses, outcomes, and interventions for patient education; implementation, evaluation, and documentation of patient education.
Chapter 11 - Nurse note documentation, level 3. After completing Chapter 11, the students will be able to: Carry out documentation of patient education and response, identify patient response to interventions, carry out documentation re-assessment/revision of goals, use Todo/Reminders within the Nurse Note.
Chapter 12 - Advanced EHR functionality. After completing Chapter 12, the students will be able to: Use EHR to order diagnostic tests, carry out a chart evaluation, use a new note to create an addendum to a nurse note, carry out printing a nurse note, carry out exporting and printing elements of a patient’s chart.
Every year an estimated three million newborn babies die during the first week of life due to problems such as sepsis, tetanus, or asphyxia, or problems associated with trauma, low birth weight, or preterm birth. This guide is written for the doctors, nurses, senior midwives, and other health care workers at the first referral level in low resource settings who are responsible for the care of newborn babies with problems during the first week(s) of life.