1. 9-1 Chapter 9 Routine Documentation © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

2. 9-2 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

3. 9-3 LO 9.1 TODO S AND REMINDERS

4. 9-4 LO 9.1 ToDos and Reminders Electronic task list – Personal use – May be sent to others – May be scheduled to send at later date

5. 9-5 LO 9.2 INTERNAL MESSAGES

6. 9-6 LO 9.2 Internal Messages Internal Messages – Intra- and interoffice mail function – May be patient related or non-patient related Patient related saved in patients 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

7. 9-7 LO 9.3 IMMUNIZATION RECORD

8. 9-8 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

9. 9-9 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

10. 9-10 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)

11. 9-11 LO 9.4 PATIENT INSTRUCTIONS

12. 9-12 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/PostmarketDr ugSafetyInformationforPatientsandProviders/UCM111 085 )http://www.fda.gov/Drugs/DrugSafety/PostmarketDr ugSafetyInformationforPatientsandProviders/UCM111 085 – National Institutes of Health Medline Plus Webpage (http://www.nlm.nih.gov/medlineplus/medlineplus.ht ml )http://www.nlm.nih.gov/medlineplus/medlineplus.ht ml

13. 9-13 LO 9.4 Patient Instructions Nurse ultimately responsible – Content of patient instructions – Evaluation and documentation of patient understanding

14. 9-14 LO 9.5 DRAW PROGRAM

15. 9-15 LO 9.5 Draw Program Photographs and drawings – Supplement narrative descriptions Wound stages Effectiveness of treatment Injuries/conditions present on admission

16. 9-16 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)

17. 9-17 LO 9.5 Draw Program Photos useful with the following POA conditions – Pressure ulcers – Injuries due to falls – Vascular catheter-associated infections