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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.
12-1 Chapter 12 Advanced EHR Functionality McGrawHill © 2012 The McGrawHill Companies, Inc. All rights reserved 12-2 Chapter 12 Content LO 12.1 LO 12.2 LO 12.3 LO 12.4 LO 12.5 Diagnostic Tests Chart Evaluations Addenda to a Nurse Note Printing a Nurse Note Exporting and Printing the Chart 12-3 LO 12.1 DIAGNOSTIC TESTS 12-4 LO 12.1 Diagnostic Tests • Processing diagnostic tests – Provider orders test – If Computerized Physician Order Entry (CPOE) not in use, personnel submit order to appropriate department • Imaging • Lab – Diagnostic department performs test – Results entered into EHR – Results available to nurse/provider 12-5 LO 12.1 Diagnostic Tests • Communication of diagnostic test results – Most EHRs have alerts for abnormal results – Primary provider must be notified of most abnormal results • Nursing judgment required • Nurse must know underlying etiology and patient trends 12-6 LO 12.1 Diagnostic Tests • Critical tests – Delineated by facility – Requires that provider notified of results even if normal • Critical results – Delineated by facility – Grossly abnormal results that require immediate provider notification 12-7 LO 12.1 Diagnostic Tests • Required documentation – Name of primary care provider notified – Date and time notified – Results of test reported – Provider’s response • No new orders • New orders received 12-8 LO 12.1 Diagnostic Tests • Failure to communicate lab results as indicated – May constitute nursing negligence – Follow facility chain-of-command policy if unable to reach provider 12-9 LO 12.2 CHART EVALUATIONS 12-10 LO 12.2 Chart Evaluations • Chart evaluations – Provide mechanism for determining when health promotion and disease prevention interventions needed • Screening tests/exams • Immunizations – Based on gender, age, personal and family health history – Improves adherence to practice guidelines 12-11 LO 12.2 Chart Evaluations • Use of guideline reminders – Patient has right to refuse • Document refusal – Provider uses clinical judgment for recommendations 12-12 LO 12.3 ADDENDA TO A NURSE NOTE 12-13 LO 12.3 Addenda to a Nurse Note • Addendum = late entry – Used to add information omitted from original note – Includes information about actual date and time of occurrence 12-14 LO 12.4 PRINTING A NURSE NOTE 12-15 LO 12.4 Printing a Nurse Note • Rarely required – Nurse note may be printed when transferring patient to another facility without EHR • Follow facility policy for release of records 12-16 LO 12.5 EXPORTING AND PRINTING THE CHART 12-17 LO 12.5 Exporting and Printing the Chart • Legal considerations – The Medical Records Confidentiality Act of 1995 • First comprehensive federal legislation protecting personal health information • Requires individuals to consent to release of health information for treatment or payment – Individual state laws also regulate confidentiality of health records – In most cases, patient health records can only be released to others with the patient’s consent 12-18 LO 12.5 Exporting and Printing the Chart • Release of records – Healthcare facilities have ‘release of records’ forms • Privacy of records – Federal law requires healthcare providers to employ security measures to ensure privacy of protected health information during electronic transmission .. .1 2- 2 Chapter 12 Content LO 12. 1 LO 12. 2 LO 12. 3 LO 12. 4 LO 12. 5 Diagnostic Tests Chart Evaluations Addenda to a Nurse Note Printing a Nurse Note Exporting and Printing the Chart 1 2- 3 LO 12. 1... received 1 2- 8 LO 12. 1 Diagnostic Tests • Failure to communicate lab results as indicated – May constitute nursing negligence – Follow facility chain-of-command policy if unable to reach provider 1 2- 9... • Document refusal – Provider uses clinical judgment for recommendations 1 2- 12 LO 12. 3 ADDENDA TO A NURSE NOTE 1 2- 13 LO 12. 3 Addenda to a Nurse Note • Addendum = late entry – Used to add information