powerpoint presentation on nursing documentation

• My presentations

Auth with social network:

Download presentation

We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!

Presentation is loading. Please wait.

Documentation of Nursing Care

Published by Amy Mosley Modified over 5 years ago

Similar presentations

Presentation on theme: "Documentation of Nursing Care"— Presentation transcript:

Concept Map as the Basis of Documentation 余 靜 雲余 靜 雲.

PATIENT MEDICAL RECORDS

15 The Health Record.

Documentation and Reporting Teresa V. Hurley MSN,RN.

Documentation NUR 111.

Learning objectives:- 1. Introduction. 2. Define health record. 3. Explain types of health record. 4. Mention purposes of health record. 5. List general.

Implementation By Patricia M. Dillon Updated Spring 2010 Prof. Unn Hidle.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 9 Recording and Reporting.

Documentation for Acute Care

Documentation and Reporting

a judgment of what constitutes good or bad Audit a systematic and critical examination to examine or verify.

RENI PRIMA GUSTY, SK.p,M.Kes

Medical Records Office Management.

Documentation and Informatics in Nursing Entry Into Professional Nursing Summer 2009.

Documentation PN 103. Introduction The “chart” = health care record – LEGAL record The process of adding written information to the chart is called: –

Foundation of Nursing Documentation in nursing

Communication is Vital! Technology is your friend!

Quality Improvement Prepeared By Dr: Manal Moussa.

Presented by,Shandy Adamson.  Identify seven reasons as to why documentation is important  Learn how to document properly  Describe different document.

Elsevier items and derived items © 2014, 2010 by Mosby, an imprint of Elsevier Inc. All rights reserved. Chapter 5 Communicating with the Health Team.

About project

© 2024 SlidePlayer.com Inc. All rights reserved.

• Customer Favourites

Nursing Documentation

Powerpoint Templates

Icon Bundle

Kpi Dashboard

Professional

Business Plans

Swot Analysis

Gantt Chart

Business Proposal

Marketing Plan

Project Management

Business Case

Business Model

Cyber Security

Business PPT

Digital Marketing

Digital Transformation

Human Resources

Product Management

Artificial Intelligence

Company Profile

Acknowledgement PPT

PPT Presentation

Reports Brochures

One Page Pitch

Interview PPT

All Categories

• You're currently reading page 1

Stages // require(['jquery'], function ($) { $(document).ready(function () { //removes paginator if items are less than selected items per page var paginator = $("#limiter :selected").text(); var itemsPerPage = parseInt(paginator); var itemsCount = $(".products.list.items.product-items.sli_container").children().length; if (itemsCount ? ’Stages’ here means the number of divisions or graphic elements in the slide. For example, if you want a 4 piece puzzle slide, you can search for the word ‘puzzles’ and then select 4 ‘Stages’ here. We have categorized all our content according to the number of ‘Stages’ to make it easier for you to refine the results.

Category // require(['jquery'], function ($) { $(document).ready(function () { //removes paginator if items are less than selected items per page var paginator = $("#limiter :selected").text(); var itemsperpage = parseint(paginator); var itemscount = $(".products.list.items.product-items.sli_container").children().length; if (itemscount.

• Anatomy (23)
• Brochures Layout (1)
• Business Plan Word (12)
• Business Plans (1)

• Preferences

Skilled Nursing Documentation - PowerPoint PPT Presentation

Skilled Nursing Documentation

Print full name, signature and initials or responsible nurse and supervising rn ... supervisory visits should be made on-site (direct) every 30 calendar days. ... – powerpoint ppt presentation.

• Anne Young, R.N.
• Department of Medical Assistance Services
• October 6, 2009
• Services are to be
• Rendered in accordance to the licensing standards and criteria of the Virginia Board of Nursing.
• Performed by a Virginia licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) under the supervision of an RN.
• Ordered by MD, NP or PA
• The supervision of the LPN is to be consistent with the Board of Nursing regulations.
• DMAS requirement is minimum 30-90 days depending on type of service and childs medical condition. More medically fragile more frequent supervision.
• Skilled nursing must be part of the IEP or the IEP must be amended to include the skilled nursing service.
• The service provider must be employed by the school division or under contract to the school division.
• All skilled nursing services must be directly provided and medically necessary.
• Services deemed not medically necessary on quality management review, will not be covered.
• Services will be consistent with skilled nursing services within the scope of their practice.
• These services can include but are not limited to
• Dressing changes
• Urinary catheterizations
• Medication Administration
• Completed by RN
• Admission / re-admission to service
• Significant change
• Upon order of MD, NP, PA
• Current medical findings
• Clinical signs and symptoms
• Needs and deficits
• Services will be directly and specifically related to an active, written plan of care (POC).
• POC is to be part of the nursing record and is the documentation for services.
• The POC is based on MD, PA or NP written order for skilled nursing services.
• The RN is to establish, sign, and date the POC.
• Medicaid billing can precede POC date up to 21 days prior to the signature on POC.
• However services may not begin prior to date treatment is prescribed by MD, NP or PA.
• The POC is to be periodically renewed or updated by an MD, PA or NP.
• Usually this is done at the beginning of each school year or at anytime the MD/PA/NPs orders are changed.
• Must include
• Medical condition(s) to be addressed
• Goals and objectives
• Treatment and procedures required by nurse
• Time tables (date and frequency)
• Actual services to be delivered
• Prescriber of services
• Date of POC implementation
• Documentation of RN or LPN
• Signed and dated
• Services shall be specific and provide effective treatment for the childs condition in accordance with accepted standards of skilled nursing practice.
• Skilled nursing services that exceed the MD, PA or NPs written order for skilled nursing services will NOT be reimbursed by DMAS.
• A copy of the Plan of Care shall be given to the childs Medicaid Primary Care Physician.
• Reviewed at least annually.
• Documented by the responsible nurse
• Time of day
• Amount of time
• Actual nursing procedure rendered
• Students response to treatment
• V variance from normal or standard. Include written explanation in Comment section
• Actions related (calling parents, physician, etc.)
• Print full name, signature and initials or responsible nurse and supervising RN if applicable.
• Dates and times of nursing service entered by the responsible nurse
• Name and Medicaid / FAMIS ID of the child on each page of the nursing record
• Services which have been delivered and for which reimbursement from Medicaid is to be claimed, must be supported with documentation.
• The POC will include any prescribed drugs which are part of the
• Individualized Educational Program (IEP)
• Including dose, frequency and route
• Follow the Specialized Health Care Procedures Manual
• Changes from the MD/NP/PA written order
• All documentation shall be signed and dated by the nurse performing the service
• Skilled nursing services may include extensive documentation
• Documentation shall be written
• Immediately or as soon thereafter as possible
• After the procedure or treatment was implemented
• Make sure to include the date and time
• Skilled nursing services documentation will be in accordance with the
• Virginia Board of Nursing
• Department of Health Professions
• Department of Education statues, regulations and standards relating to school health and
• School Division Medicaid Manual
• Chapter VI (Utilization Review)
• If nursing procedures are performed by an LPN, they must be supervised by a RN in accordance with the Board of Nursing Regulations.
• RN to review the childs progress and make any adjustment to goals or treatment modalities
• LPNs have to be supervised by RN
• Supervision must be documented by the RN within a minimum of 30-90 calendar days
• Supervisory visits are required as often as needed to ensure both quality and appropriateness of services.
• Supervisory visits should be made on-site (direct) every 30 calendar days.
• On-site visits may be conducted more frequently than every 30 calendar days depending on intensity and level of nursing services the child is receiving as well as the license requirements of the RN and the LPN.
• If an on-site visit is not possible every 30 calendar days, then an indirect visit may be conducted via telephone or off-site.
• On-site vs. indirect supervision as well as frequency depends on condition of the child as well as license requirements of RN.
• An on-site visit must be conducted at least every 90 calendar days.
• Quality management reviews will be performed randomly by DMAS to determine if services are appropriately provided to Medicaid and FAMIS recipients and to ensure the services are medically necessary and appropriate.
• Failure to document services in the childs school nursing record will be considered not performed and payment may be revoked.
• Services that can be provided by someone other than the skilled nursing professional will not be reimbursed by DMAS.
• Unless a concurrent nursing service is being provided to the individual.
• Unskilled services may be reimbursable under personal care assistant services.
• T1001 for an RN assessment
• T1002 for services performed by RN
• T1003 for services provided by LPN
• A unit is 15 minutes of nursing care
• SN services will be limited to 6.5 hrs per day or 26 units per day
• Need to exceed limits/day?
• Attach medical justification for additional authorization
• To calculate these services
• Take the average amount of time for the procedure
• Multiply by the number of times a month the service is delivered
• Divide by 15 (a unit) to get the total number of units to be billed.
• Ex. 5 mins to give meds x 18 times a month90 mins div by 15 mins 6 units.
• If the total number of units billed ends up with a fraction of a unit, round to the nearest unit
• 50 minutes of care / 15 3.33 3 units
• 100 minutes of care / 15 6.66 7 units
• Regular school year is 180 days
• May vary among school divisions
• Services during the summer school sessions are billable as well.

PowerShow.com is a leading presentation sharing website. It has millions of presentations already uploaded and available with 1,000s more being uploaded by its users every day. Whatever your area of interest, here you’ll be able to find and view presentations you’ll love and possibly download. And, best of all, it is completely free and easy to use.

You might even have a presentation you’d like to share with others. If so, just upload it to PowerShow.com. We’ll convert it to an HTML5 slideshow that includes all the media types you’ve already added: audio, video, music, pictures, animations and transition effects. Then you can share it with your target audience as well as PowerShow.com’s millions of monthly visitors. And, again, it’s all free.

About the Developers

PowerShow.com is brought to you by  CrystalGraphics , the award-winning developer and market-leading publisher of rich-media enhancement products for presentations. Our product offerings include millions of PowerPoint templates, diagrams, animated 3D characters and more.

Pump up your PowerPoint® presentations

As nurses , we use our education skills to deliver health messages every day. We teach patients about specific diseases or interventions in clinical settings. We advise colleagues on how to use new technology. And we serve as preceptors to nursing students or novice nurses.

But while one-on-one teaching may come naturally to us, giving a gripping visual presentation may be a challenge. We’ve all seen PowerPoint® presentations. Some are so engaging that time flies from the instant they begin to the moment we exit. But in others, the presenter fails to engage the audience, leaving session objectives unmet—and leaving audience members counting the minutes until the presentation ends.

Using engagement strategies combats boring presentations and keeps the audience attentive. These strategies turn passive audience members into active participants of the interactive discussion. We’re moving away from traditional lecture formats where a “talking head” delivers information to deposit into others’ brains. Promoting interactivity, encouraging questions, and using visual aids in an interesting way are more effective strategies for delivering content and helping the audience understand it. Similarly, using multiple teaching strategies lends itself to individuals with different learning styles.

PowerPoint software can transform simple words on a single slide into a captivating, dynamic presentation. This article discusses specific PowerPoint features to consider using for your next presentation.

Keep slide design simple

After you complete the outline for your presentation, you’ll need to choose a slide background or design. A simple design is ideal. Busy backgrounds can interfere with the text and images you add to the slide. Use dark-colored text with a light background, or vice versa. Also, use transitions to add a progressive effect when moving from one slide to the next.

Avoid too many animations on any one slide, as this can distract the audience. If you want to use animations, use the same type for all slides. For example, don’t have text “fly” in from the bottom of one slide, then from the top on the next slide, then from the left, and so on. Choose one type of animation and stick to it.

Write succinct titles

Titles help readers visualize a road map for the “journey” of your presentation. Keep titles short and concise, using no more than a few words. If you’re using graphics, charts, or graphs, your titles should highlight the main focus.

Use transition slides

Usually, transitions to new content are presented orally. But you can also use “title” slides, containing only the title of the next section. Besides signaling the audience that you’re moving on to a new topic, these slides remind you to bring closure to the previous topic.

Choose a readable font

Choose a clean font for readability. Font size should be large enough so people at the back of the room can read all the copy on the slide. Font color should be black or another dark color to contrast the light background—or if you’ve opted for a dark background, use a white font. Avoid yellow, red, and orange fonts because they can be hard to read.

Stick to the 6-by-6 rule

Think back to the last presentation you sat through. Was there too much text on the slides? Did the presenter read the text verbatim rather than let the presentation serve as an outline? To avoid this mistake in your presentations, follow the 6-by-6 rule: On any given slide, use no more than six bullet points and no more than six words per bulleted statement.

State the objectives

To better engage your audience, share your learning goals with them. Specify exactly what they should learn by the end of your presentation. Objectives are statements that set goals. To write objectives, start with an action verb and end with a content statement; for example: “Describe needle lengths for different types of injections.” The objective starts with the action verb “Describe” and ends with the content statement “needle lengths for different types of injections.” For each objective, tell the audience how you will meet it. When you come to the end of your presentation, you can use these objectives to evaluate how much the audience learned.

Use graphics effectively

When teaching patients, nurses typically use handouts, pictures, or demonstrations based on the patient’s learning style (visual, auditory, or kinesthetic) and learning needs based on age, reading level, and language. Using graphics captures most learning styles and needs.

Put a graphic on most slides to illustrate the point you’re trying to make. Limit graphics to one per slide to help your audience focus on what you have to say as you refer to that image. If you want to call attention to a specific part of the image, you can add an arrow, shape, or textbox. (See Replacing text with images by clicking the PDF icon above.) Be aware that PowerPoint has a feature called SmartArt, which converts text into linear, progressive, or circular visual aids.

Keep in mind that charts and graphs are a great way to present statistics. For example, you can show percentages with a pie chart or depict trends over time with a line graph.

Vary your teaching strategy

During your interactive presentation, vary your teaching strategy every 10 minutes. To do this, you can use links to websites, videos, or games. For example, share a short YouTube video to add a visual and auditory component.

Another way to vary your strategy is to post a discussion question on a slide and take responses from the audience, or give them a group activity to work on, with activity instructions shown on the slide. Polls are another way to engage the audience. Although normally placed at the beginning of the presentation, polls can be useful anywhere. You can post a question on a slide and ask the audience to raise their hands in response to each answer option. Or you can add true/false, multiple-choice, or fill-in-the-blank questions throughout your presentation to evaluate learning. That way, you can get immediate feedback on the audience’s understanding of the content you’ve presented.

Use online tools if appropriate

If you wish to include an online interactive tool in your presentation, make sure your computer or tablet is connected to the Internet to access those resources. Also, share additional credible and reliable resources on your reference page so audience members can access them afterward.

Include interactive dialogue variations

Many of us can recall narratives or anecdotes from a presentation we’ve seen. I vividly remember certain stories told by faculty members in my academic career; their application of content helped me connect the knowledge to real life.

Similarly, you can place a word, phrase, or picture on your slide to remind you of an anecdote or narrative you want to share. Instead of putting the entire anecdote or narrative on the slide word for word, use the slide only to prompt you to relate it to the audience orally.

Create “empty” handouts

When I last attended a nursing conference, the presenter gave the audience handouts. Then she turned her back to us and simply read from her slides. With each slide, I grew less engaged. Eventually, I left to attend another presentation. Why not? All of the content was on the handout, word for word.

To avoid this situation, create a second, slightly different version of your presentation that contains information not included on the slides you’ll present—what’s commonly called an “empty” outline or handout. Save this second version on your computer under a new filename to avoid confusing it with the full presentation; then make printouts of the “empty” version to hand out to the audience. Doing this keeps the audience engaged as they fill in answers to test questions, grids, and discussion questions. For example, you may want to ask the audience the advantages and disadvantages of using the deltoid muscle for intramuscular injections. Leaving the corresponding slide empty encourages them to think on their feet. Later, you can share the correct answers on the slide or verbalize the correct answers during your presentation. (See The“empty” slide or handout by clicking on the PDF icon above.)

Although your audience will need to take notes to complete their handouts, you don’t want them to have to write too much. Balance the need to give them enough content to stay engaged with the need to not reveal your entire presentation.

Other presentation tips

Ultimately, PowerPoint can only go so far in helping you engage your audience. As the presenter, you must be able to “read” your audience—and this comes with experience. For instance, if you “read” that some people are getting bored, consider giving the audience breaks, changing activities, or asking discussion questions to keep them attentive.

Here are some other helpful tips for both novice and expert presenters:

• Present one idea per slide.
• Keep your talk to no more than 1 to 2 minutes per slide.
• Use a pointer or the pen highlighter feature to highlight important content.
• Use narratives and anecdotes for a more appealing presentation. For example, when sharing a story about your experience administering injections, use the “W” or “B” key on the keyboard to either white out (“W” key) or black out (“B” key) the screen, respectively, when visuals aren’t needed. The audience will look up from their handouts and focus on you, the presenter.

Above all, remember that the slides are meant to serve as an outline. As the nursing expert and content expert, you are the primary focus of the presentation. You become the primary focus by demonstrating knowledge and letting your slides serve as an outline—all the more reason to design the most engaging presentation you can.

Click here for a complete list of references.

Tresa Kaur Dusaj is an assistant professor of Nursing and Health Studies and coordinator of the MSN Nursing Education Track at Monmouth University in West Long Branch, New Jersey.

NurseLine Newsletter

• First Name *
• Last Name *
• Hidden Referrer

*By submitting your e-mail, you are opting in to receiving information from Healthcom Media and Affiliates. The details, including your email address/mobile number, may be used to keep you informed about future products and services.

Test Your Knowledge

Recent posts.

Effective clinical learning for nursing students

Nursing professional development at night

Engaging nurses in scholarly work

Mentorship matters

2023 nursing trends and salary survey results

NCLEX vs Next Generation

Patient care assistant training

Re-imagining nursing’s social contract with the public

2022 nursing trends and salary survey results

What’s the economic value of nursing?

Is there a nurse in the House? Or the Senate?

Addressing the nurse faculty shortage

Recruiting Millennial and Gen Z nurses

Clinical conferences

Travel nursing nuts and bolts

Got any suggestions?

We want to hear from you! Send us a message and help improve Slidesgo

Top searches

Trending searches

infertility

30 templates

linguistics

89 templates

15 templates

28 templates

public health

35 templates

holy spirit

38 templates

Nursing Presentation templates

They draw your blood when you have a blood test. they give you vaccinations. they assist doctors with critical tasks and help the elderly if they need it. that's right, we're talking about nurses take a look at these designs about nursing..

Aquatic and Physical Therapy Center

The way we present our company says a lot about it. This time we bring you a perfect template for aquatic therapy centers. Its background is white, which contrasts with the waves in blue and gray tones, simulating the movement of water. Edit the graphics, show your milestones and explain...

French Cultural Studies - Doctor of Philosophy (Ph.D.) in French

Download the French Cultural Studies - Doctor of Philosophy (Ph.D.) in French presentation for PowerPoint or Google Slides. As university curricula increasingly incorporate digital tools and platforms, this template has been designed to integrate with presentation software, online learning management systems, or referencing software, enhancing the overall efficiency and effectiveness...

Cream & Pastel Palette Healthcare Center Characters

Let us introduce you to a new way of presenting healthcare centers. Did you think that we were going to use blue? Tut-tut! This time, the palette revolves around cream (the color of the backgrounds) and other pastel tones. As you explain in detail (or in brief) your healthcare services,...

Hand Drawn Style Healthcare Center

If you need to present a healthcare center, the overall aesthetic you might be looking for is something peaceful and pretty. Something that makes your center look approachable and safe. In that case, we have the perfect template for you! These slides will make your presentation super calm and attractive:...

Gynecology Breakthrough Theme

Download the Gynecology Breakthrough Theme presentation for PowerPoint or Google Slides.Treating diseases involves a lot of prior research and clinical trials. But whenever there’s a new discovery, a revolutionary finding that opens the door to new treatments, vaccines or ways to prevent illnesses, it’s great news. Should there be a...

Clinical Case 06-2023

Slidesgo is back with a new free medical template, perfect for a presentation about a clinical case. The design is very appealing, so these slides are a nice tool to provide a lot of useful information for doctors and researchers.

Oral Cavity Diseases: Gingivitis

Download the Oral Cavity Diseases: Gingivitis presentation for PowerPoint or Google Slides. Taking care of yourself and of those around you is key! By learning about various illnesses and how they are spread, people can get a better understanding of them and make informed decisions about eating, exercise, and seeking...

Premium template

Unlock this template and gain unlimited access

Pastel Palette Doctor Theme

Presentations on health and medical topics can be challenging to create, but this Google Slides & PowerPoint template is here to rescue you! This multi-purpose layout is designed with blue pastel tones, providing a professional and calm environment to showcase your medical expertise to colleagues, students, or patients. The template...

National Library of Medicine

How many books about medicine can there be? And medical centers? We can't give you an exact number, but what we can offer you is a template for Google Slides and PowerPoint to present your medical center. In a simple, but direct style, you can talk about your center, where...

Clinical Case 04-2023

When trying to prevent diseases, information is key, and if it’s reliable, all the better. With this new free medical template, you can show the results of a clinical case, including the symptoms, the patient monitoring, the treatment and all the important data. Its design will help you grab your...

Patients and Nurses Medical Theme

As the backbone of every healthcare system, nurses play an integral role in providing top-notch patient care. Whether it's administering medication, monitoring vital signs, or simply holding a hand, these dedicated professionals are the ones keeping our loved ones safe and comfortable during their time of need. But let's not...

Anatomy & Physiology

Download the Anatomy & Physiology presentation for PowerPoint or Google Slides. Healthcare goes beyond curing patients and combating illnesses. Raising awareness about diseases, informing people about prevention methods, discussing some good practices, or even talking about a balanced diet—there are many topics related to medicine that you could be sharing...

Pregnancy Breakthrough

Giving birth to a baby is a beautiful occasion, a manifestation of love between two people. Obstetrics are key during pregnancy, so how about giving a presentation about the latest breakthrough in this field? Our free medical template will come in handy.

Uterine Hemorrhage Case Report

Download the Uterine Hemorrhage Case Report presentation for PowerPoint or Google Slides. A clinical case is more than just a set of symptoms and a diagnosis. It is a unique story of a patient, their experiences, and their journey towards healing. Each case is an opportunity for healthcare professionals to...

Alcoholism Treatment Drugs Breakthrough

Drug addictions are a difficult condition to treat, but thanks to the investigations and studies conducted by health professionals, new breakthroughs are appearing to help people who suffer them. Speak about it with this visual design for breakthrough news and share the treatment you have discovered with the medical community!...

Opioid Addiction Rehab Center

Download the Opioid Addiction Rehab Center presentation for PowerPoint or Google Slides. Hospitals, private clinics, specific wards, you know where to go when in need of medical attention. Perhaps there’s a clinic specialized in treating certain issues, or a hospital in your area that is well-known for its state-of-the-art technology....

Psychogenic Cough Breakthrough

Download the Psychogenic Cough Breakthrough presentation for PowerPoint or Google Slides.Treating diseases involves a lot of prior research and clinical trials. But whenever there’s a new discovery, a revolutionary finding that opens the door to new treatments, vaccines or ways to prevent illnesses, it’s great news. Should there be a...

Clinical Case 01-2023

Present your clinical case to the medical community with this dynamic and engaging presentation by Slidesgo. Who said science can’t be creative and fun?

• Page 1 of 146

New! Make quick presentations with AI

Slidesgo AI presentation maker puts the power of design and creativity in your hands, so you can effortlessly craft stunning slideshows in minutes.

Register for free and start editing online

Electronic Nursing Documentation

Oct 20, 2014

650 likes | 900 Views

Electronic Nursing Documentation. Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #:. Nursing Unit. General Admission.

Share Presentation

• health fund
• admission date
• expiry date
• actual accommodation occupied
• private health fund information

Presentation Transcript

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Personal Details: Mr / Mrs / Miss / Ms Surname......................................................................................................................................................... Given Name: ............................................................................... Middle Name/s: ........................................................................... Gender: Female Male Date of birth ........../........../.......... Age:........................... Medicare Number: ........................................................................................................................ Expiry date: ........./........./.......... The number next to your name on the medicare card: .................... Telephone No.: (Home) ......................................... (Business) ......................................... Mobile No.: .......................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Email address:................................................................................................................................................................................... Country of birth: ................................................................................... Language spoken:.............................................................. Interpreter Required? Yes No Aboriginal origin Yes No Torres Strait Islander origin Yes No Marital Status: Married Defacto Never married Widowed Separated Divorced Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Religion: ................................................. This information enables us to provide appropriate services to you whilst you are here and is generally available to accredited chaplains at this facility. If you want your religion withheld from the chaplaincy service please tick this box Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Permanent Address: Street number or property name:................................................ Street Name: ............................................................................... Suburb/Town: ............................................................................. State: .............................................. Postcode: ......................... Temporary Address for Visitors (Overseas or Country Patients): Street number or property name:................................................ Street Name: ............................................................................... Suburb: ...................................................................................... State: .............................................. Postcode: ......................... Telephone No.: (Home) ......................................... (Business) ......................................... Mobile No.: .......................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission General Practitioner / Local Doctor: Surname: ................................................................................................ Given Name:.................................................................... Address: ............................................................................................................................................................................................ Telephone No: ........................................................................... Fax No:......................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Hospital has an active Mailing Program. Would you be happy to receive this information? Yes No Signature: ................................................. Date: ........./........./......... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission P.A.C. date: ........../........../.......... Ward: ................ Initial Admission date: ........../........../.......... Updated on Computer Office Use Only Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission FINANCIAL DETAILS 1. Centrelink No:................................................ (if applicable) 2. Private Health Fund Information: Are you a member of a Health Fund? Yes No Name of Fund:....................................................................................................................................................................................... Membership No.: ............................................................................... Table of Cover Basic Top Cover Date joined Fund: ........../........../.......... Date joined current Table of Cover: ........../........../.......... Excess Payable? No Yes Amount: Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Person Responsible for Account (contributor): Relationship to Patient:.......................................................................................................................................................................... Mr / Mrs / Miss / Ms Surname: ............................................................................................................................................................. Given Name:.......................................................................................................................................................................................... Home phone: ............................................................................. Other phone:..................................................................................... Street No. or Property Name: ................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Your Preferences: Have you elected to be treated as a Private Patient? Yes No If yes, please specify your preferred accommodation. Single Shared Whilst every effort will be made to provide the accommodation you request, this is subject to availability at the time of admission. Accommodation costs will be billed to the actual accommodation occupied. Thank you for supporting Hospital. Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Veterans’ Affairs: Are you a Veterans’ Affairs patient? Yes No Do you need DVA transport Yes No Veterans’ Affairs Card Number: ................................... Card colour: White Gold Orange Serving Unit: ................................................................ (eg. 2nd / 1st InF BN) Veterans who do not wish to receive a visit by an Ex-service/Volunteer organisation representative (ESO) must advise the hospital. If you want the above information withheld from the ESO please tick this box Army R.A.A.F. P.O.W. Europe Navy T.P.I. Veteran Japan Other Vietnam Veteran Korea War Widow Vietnam Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Workers’ Compensation / Third Party Liability Claims: Are you entitled to Third Party Liability Claim? Yes No Are you entitled to Workers’ Compensation (approval required)? Yes No Did the accident occur in the course of your employment? Yes No Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Employer Name:.................................................................................................................................................................................... Employer Address:........................................................................................................................................... Postcode: .................. Contact Name:....................................................................................................................................................................................... Claim Number:....................................................................................................................................................................................... Insurer Name:..................................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Date of Injury: ........../........../.......... Solicitor’s Name: ................................................................................................. Telephone No.:........................................................ Address: ................................................................................................................................................................................ Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Overseas Visitor: Are you a member of a health fund / Travel Insurance? Yes No (If yes, complete Health Fund details in paragraph 2, and bring documentation of your insurance with you) Overseas Address:........................................................................................................................................................................... Town / City: ........................................................................... Postcode .................... Country:..................................................... Passport number: ............................................................................................................. Date of entry visa ........../........../.......... Reciprocal Rights: Yes No Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Person to Contact: Relationship to patient: ................................................................................................... (eg. neighbour, wife, sister, partner, etc.) Surname:.......................................................................................................................................................................................... Given Name: .................................................................................................................................................................................... Gender: Male Female D.O.B.: ........../........../.......... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Street Address:.................................................................................................... Suburb / Town: .................................................. State:.......................................................................................................................................................... Postcode: ................... Home Phone Number: ..................................................................................................................................................................... Work Phone Number: ...................................................................................................................................................................... Mobile Phone Number: .................................................................................................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Next of Kin / Power of Attorney: Relationship to patient: ............................................................................................. (eg. husband, wife, other relative, child, etc.) Surname:.......................................................................................................................................................................................... Given Name: .................................................................................................................................................................................... Gender: Male Female Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission D.O.B.: ........../........../.......... Street Address:.................................................................................................... Suburb / Town: .................................................. State:.......................................................................................................................................................... Postcode: ................... Home Phone Number: ..................................................................................................................................................................... Work Phone Number: ...................................................................................................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission COMMENTS: ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... ......................................................................................................................................................................................................... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission .............................................................................................. ........../........../........ Patient’s/ Guardian Signature Date Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission CANCELLATION / DEFERMENT FORM Surname: Given Name/s: Address: Date of Birth: ......../......../........ Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Deferment of Admission: I request that my admission be deferred. My reason for requesting deferral is: I am going away on holidays. Inconvenient at this time. Work commitments prevent me from being admitted. Home support not available. Other (please specify) ............................................................................................................ Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission I will be available after ........./........./......... Please note: If you defer your admission on TWO occasions for non-medical reasons your name will be removed from the waiting list. Signature:.................................................... Date ........./........./......... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Cancellation of Admission: I request that my admission be cancelled. My reason for requesting cancellation is: I have had the procedure done elsewhere. My doctor advises that the procedure is not necessary. I do not wish to have the procedure performed. Other (please specify) ............................................................................................................ ............................................................................................................ Signature:.................................................... Date ........./........./......... Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit General Admission Official Use Only Previous Admission Date Previous Procedure Date Previous PAC Date Cancellation/Deferment Acknowledged Visit ID WARD Fin Class Signature:................................... Date: ...../...../..... New Admission Date Procedure Date New PAC Date Signature Patient advised by: Transport Arrangements Signature / Date Phone / Letter / Fax / Rooms SPECIALIST PROCEDURE Nursing Assessment Physicians’ Order Protocol Per Diagnosis Plan of Care Nurses’ Progress Notes Discharge Planning

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment OXYGEN: CardiovascularRespiratory Skin warm to touch? Respiratory rate      Rhythm      Skin color      Audible breath sounds      Color of nail beds      Dyspnea - at rest on exertion Temperature      Location      Cough Sputum None Radial pulse rate       Rhythm       Smokes Packs per day   Apical pulse rate      Rhythm       * Medications      BP: Location     Position       Laboratory data       Peripheral Pulse       Pulse ox      Equipment in use (O2 , flow rate)      Pain Scale # NU FA Additional data:       Capulary Refill      

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment FLUIDS AND ELECTROLYTES: Skin turgor - Normal Poor Presence of thirst some, does not drink water Tongue and lips      Nausea or vomiting Mucous membranes      Presence of edema none Fluid intake for previous 24 hrs       *Medications      Fluid restriction (Note amt q 224 hrs & distribution q shift) Laboratory data       Equipment in use       Additional data:     

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment NUTRITION: Ht     Wt       Dentures? Upper Lower Partial Ordered diet      Recent change in weight?       Preferred foods      Problem chewing? Swallowing? Heartburn? Indigestion? % of meal consumed      *Medications      Dietary supplement       Laboratory data      Assistance with meals       Equipment in use (N/G tube, PEG tube, G tube, etc.)      Additional data:     

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment ELIMINATION: Urinary: Bowel sounds      Abdominal distention Amount     Color       Frequency       *Medications      Bathroom Commode Bedpan Incontinent Laboratory data      Total output for previous 24 hrs    ml Equipment in use      Bowel: Amount      Color      Frequency      Additional data:      Normal for client Constipated Diarrhea Incontinent

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment MOBILITY AND ACTIVITY: Fall Assessment Score      Muscle strength - Handgrips equal Fall risk - High Moderate Low Foot pushes equa l Physical therapy working with client?      ROM - Normal Limited Severely limited *Medications      Ability to move in bed - Self Assist Immobile Laboratory data      OOB - Chair Wheelchair Geri-chair Equipment in use (assistive devices)       Ability to transfer - Self Assist      Additional data:      Distance able to ambulate       Gait     

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment REST, SLEEP AND PAIN: Reported quality of sleep in hospital      Observable signs of pain - Grimacing Posturing Moaning C/O Pain - *Medications_____________________________________________ Location       Pain Scale # NU FA Intensity      Additional data:      Duration     

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Vision: Skin integrity: Able to see without glasses Needs glasses Intact Able to read own menu Reddened Location      Watches TV from      ft Blancing erythema Non-blancing erythema *Medications      Incision/Lesion/Wound Location      Approx. size in cms      Hearing: Appearance      Responds to normal voice tones Treatment (dressings, etc.)      Hearing aid Deaf *Medications     

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Speech: Allergies      Clear Garbled Incomprehensible Laboratory data      Mental status: Environment: Alert Lethargic Unresponsive Physical surroundings      Oriented to - Person Time Place *Medications      *Medications      Additional data:      Braden/Norton Score #       Risk: High Moderate Low

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Client report of family/friends      Next of kin (chart)             Religious affiliation      Indicators - Cards Flowers Family pictures Additional data:     

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Family role       Grooming equipment at bedside:      Occupation      Brush/comb Toothbrush Toothpaste Interest in appearance      Other personal toiletries Additional data:     

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Client report of satisfaction with life       Additional data:      Independence      Creativity     

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Nursing Assessment Nursing Admitting History

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order REQUIRED INFORMATION FOR REFERRAL Patient’s Medical Record Number OR Patient First Name _________ _____________________________________ Patients Last Name ________________________ Select Appropriate Facility : _____________________________ Gender:  Female  Male Name of Patient’s Parent/Legal Guardian _________________________________________ Nursing Assessment

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order Chief Complaint/Reason for Referral: ________________________________________________________________ Refer To:  Emergency Medicine  Emergency Medicine + consult  Sub specialist/other  Test Only You must notify any consultants/sub specialists before initiating a referral to the Emergency Department. Sub specialist/Consultant Name: ______________________________ Service: ____________________________ Pager/Phone Number: _______________________________________ or  page on-call physician/resident Nursing Assessment

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order Referring Physician: ________________________________________Office/pager (_______)______________________ After Hours ____:____ AM/PM Call (_______)______________________________ Callback Instructions:  After MD assessment (prior to labs and tests)  After ED evaluation  Only if concerns or admitted  No callback requested Callback Physician:  Same as referring physician  On call for practice Callback Phone Number:  Same as office number  Same as after hours number  Other (_______)____________________________ Nursing Assessment

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order Call back after six hours if patient does not arrive? (Calls are made between 9 AM and midnight)  Yes  No Patient Transferred From:  Home  MD office  Other: _________________________________ Clinical information (use additional sheets if necessary): ___________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________ Nursing Assessment

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Physicians’ Order Labs/X-rays/Treatments  CBC  Blood culture  Urinalysis  Urine culture  Lumbar puncture  Electrolytes  Chest-x-ray  IV fluids  Other______________________________ Nursing Assessment

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Protocol Per Diagnosis Myocardial Infarction inbalance Oxygen (O2) demand supply Asses the severity, location & duration of pain (report) Administer O2 with semi-fowler's position Obtain a 12 lead ECG during pain Monitor vital signs Administer Nitroglycerine & Narcotic analgesics as ordered Administer & Monitor Thrombolytic therapy Ensure rest & sleep, provide a comfortable environment Monitor patient's response to drug therapy Nursing Assessment Physicians’ Order

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Protocol Per Diagnosis Myocardial Infarction decrease cardiac output Monitor cardiac rate, rythm & conduction (report any change) Observe vital signs, ECG, urine output, skin temp & colour Administer prophylactic anti-arrhythmic & other drugs as ordered Administer IV fluids Promote physical & mental rest & comfort Monitor laboratorium result Keep anti-dysrhythmic drugs & defibrillator ready Nursing Assessment Physicians’ Order

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Protocol Per Diagnosis Myocardial Infarction respiratory difficulties (dyspnoea) Asses for any dyspnoea, abnormal breath sound (report) Ensure propped up position, rest & comfort Administer O2 & drugs as ordered Psycological support, give liquid diet Nursing Assessment Physicians’ Order

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Protocol Per Diagnosis Myocardial Infarction anxiety & fear of death Encourage patient & family to express fear or anxiety by interest, listening, caring Explain the procedures being done on him Psycological & spiritual support Administer morphine or other anti-anxiety drug Nursing Assessment Physicians’ Order

Date: Rm#: Name: Age: DOB: SSS#: Responsible Party: Contact #: Address: Diagnosis: Physician: Insurance Name: Insurance #: Nursing Unit Plan of Care Problem/Need COGNITIVE AND COMMUNICATION Altered level of cognitive function due to dx of patient has: memory problems impaired decision making skills impaired ability to comprehend difficulty understanding what is being said as well as being understood

• More by User

electronic documentation clinical notes

Adding Documentation. . 1. Open the Patient's chart.. 1. You can document a Consult, Discharge Summary, H

556 views • 22 slides

Electronic health records and nursing

Electronic health records and nursing. Applications to nursing care Anne Sales, PhD RN Faculty of Nursing University of Alberta, Edmonton, Alberta. Objectives. Develop a common understanding of the challenges in developing an EHR optimized for inpatient nursing care

2.22k views • 20 slides

School Nursing Documentation For Continuity of Care

Why Document?No one ever looks at our notes

762 views • 43 slides

Documentation and Informatics in Nursing

Why Document?. Accreditation (TJC)Reimbursement (DRG's, Medicare)Communication (Continuity, education)Legal (Not documented, not done). Multi-Disciplinary Communication. Reports-Oral: End of shift WrittenRecord-Chart: Permanent, legal, healthcare management on-going accountHea

996 views • 36 slides

Paediatric Nursing Documentation Re-audit June 2007

Paediatric Nursing Documentation Re-audit June 2007. Tracy McLean – Matron Vivian Kernick – Paediatric Staff Nurse Facilitated by: The Clinical Audit and Effectiveness Department. Paediatric Nursing Documentation Re-audit – June 2007. Objective:

502 views • 16 slides

NURSING PROCESS/ DOCUMENTATION

NURSING PROCESS/ DOCUMENTATION. THE NURSING PROCESS. Includes 5 steps: Assessment Diagnosis Planning and outcome identification Implementation Evaluation. THE NURSING PROCESS (continued). A series of steps that lead to accomplishing some goal or purpose.

1.4k views • 52 slides

Horizon Expert Documentation (HED) On-line Nursing Documentation

Horizon Expert Documentation (HED) On-line Nursing Documentation. A How to Guide For IV Therapist. About HED: Nursing staff enter Vitals, I&O, Assessments, Interventions & Admission History data in HED. This data will be saved to Starpanel.

221 views • 6 slides

How does Electronic Documentation work?

How does Electronic Documentation work?. P ostal O ne ! ® Electronic Documentation. Electronic submission of postage statements and supporting documentation is required to realize all of the benefits available when using the Intelligent Mail Barcode.

311 views • 14 slides

Nursing student documentation in epic

Nursing student documentation in epic. Click on the Citrix icon bottom right hand corner of screen. Select Epic 2010 and from there select HyperSpace PLY. Log in screen in PLY - Playground. User ID: RNstudent Password: model Logins NOT CASE

2.16k views • 35 slides

Electronic Submission of Medical Documentation (esMD)

Electronic Submission of Medical Documentation (esMD). Provider Profiles Authentication Workgroup. Agenda. Face-to-Face Meeting - April, 2012. Face to Face April meeting has been scheduled for April 11-13 th Location –Westin Alexandria 400 Courthouse Square Alexandria, Virginia

420 views • 22 slides

Electronic Submission of Medical Documentation (esMD). Community Meeting. Today’s Agenda. Provider profiles authentication (PPA) use case. Use Case Development within the S&I Framework. Pilot Demonstration Projects. Standards Development Support. We are Here. Reference Implementation.

344 views • 19 slides

Electronic Submission of Medical Documentation (esMD). Agenda. Charter Review esMD Initiative Priorities esMD Requirements for the Initiative Public Participation/Stakeholder Outreach Workgroup Formation. esMD DRAFT Charter . esMD Priorities.

287 views • 10 slides

CVICU - Sat Probe Nursing Documentation

Starting: 03/11/09; WY. CVICU - Sat Probe Nursing Documentation. 1. Sat probe site assessment: Q4H - Document under “INTERVENTIONS & ACTIVITIES” on flowsheet Label “SAT PROBE SITE” and write “WNL” if asymptomatic 2. Sat probe site change: Q8H

188 views • 1 slides

Electronic Submission of Medical Documentation (esMD). Agenda. Brief background on ONC and CMS partnership Charter Review esMD Initiative Scope & Priorities Public Participation. esMD Initiative: CMS and ONC Partnership. History of esMD: esMD has been a CMS Project for 2 years

164 views • 8 slides

Documentation and Informatics in Nursing. Entry Into Professional Nursing Summer 2009. Why Document?. Accreditation (TJC) Reimbursement (DRG’s, Medicare) Communication (Continuity, education) Legal (Not documented, not done). Multi-Disciplinary Communication. Reports-Oral: End of shift

1.26k views • 36 slides

OBJECTIVES: HED Nursing Documentation

OBJECTIVES: HED Nursing Documentation. Document Interventions, Assessments Set Preferences & Create Assignment View Confirming Med Orders Commit to use HED system safety checks. GENERAL PRINCIPLES OF ASSESSMENTS. Beginning of shift or change level of care

360 views • 9 slides

Electronic Submission of Medical Documentation (esMD). Community Meeting. Today’s Agenda. Quick Review of electronic service information ( esi ). Query for Electronic Service Information – Data Set Overview – Response Detail. Provider Directory Information PD identifier and name.

243 views • 12 slides

CHAPTER 6. NURSING PROCESS/ DOCUMENTATION. THE NURSING PROCESS. Includes 5 steps: Assessment Diagnosis Planning and outcome identification Implementation Evaluation. THE NURSING PROCESS (continued). A series of steps that lead to accomplishing some goal or purpose.

2.35k views • 56 slides

Chapter 16 Nursing Documentation

Chapter 16 Nursing Documentation. medical and nursing documents. A client's medical record Temperature sheet Physician’s order sheet special nursing record chart , etc. client's record. Change-of-shift report ( 病室交班报告 ).

9.84k views • 84 slides

Coded Nursing Documentation Profile

Coded Nursing Documentation Profile. IHE Patient Care Coordination Virgina K.Saba , EdD , RN Keith Boone. Value Proposition. Coded Nursing Documentation (CND) - Plans of Care data is one of the largest gaps in hospital care delivery.

297 views • 7 slides

Nursing and Therapy Documentation Tips

Nursing and Therapy Documentation Tips. Team Documentation. What can the non-physician provider do to support medical necessity? Ensure documentation is legible and easy to navigate.

769 views • 46 slides

Horizon Expert Documentation (HED) On-line Nursing Documentation. E-training for Medical Information Services – Viewing & Printing HED Data from HED & StarPanel April, 2006. Using this tutorial. Information included on how to access and print data charted by nurses in HED

612 views • 30 slides