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Chapter 7

Ambulatory Healthcare

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

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Chapter 7 Content

LO 7.1 The Ambulatory NurseLO 7.2 Building an Office Visit NoteLO 7.3 Modifying the Office Visit NoteLO 7.4 Creating an Addendum

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LO 7.1 THE AMBULATORY NURSE

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LO 7.1 The Ambulatory Nurse

• Ambulatory nursing– Increased demand due to movement of patient

care to outpatient setting– Episodic care < 24 hours– Highly interdisciplinary

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LO 7.1 The Ambulatory Nurse

• Unique set of nursing skills– Assessment– Health promotion– Health maintenance– Patient education– Patient advocacy– Collaboration– Financial aspects of patient care

• American Association of Ambulatory Care Nurses (AAACN)

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LO 7.1 The Ambulatory Nurse

• Nurse practitioners– Advanced practice nurses– Licensed independent practitioners– Advanced education– Holistic practice– Scope of practice regulated by individual states• Assigning medical dx• Prescribing medications and treatments

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LO 7.1 The Ambulatory Nurse

• Research findings:– Nurse practitioners• Produce outcomes comparable to physicians• Provide cost-effective care• Rank higher than physicians in patient satisfaction

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LO 7.2 BUILDING AN OFFICE VISIT NOTE

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LO 7.2 Building an Office Visit Note

• Subjective Components of Office Visit– Chief complaint

• Primary reason patient seeks care• Best documented as patient quote

– Present illness• Onset• Duration• Severity• Aggravating and alleviating factors

– Review of systems• Specific data about each body system

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LO 7.2 Building an Office Visit Note

• Subjective Components of Office Visit (cont.)– Health History• Obtained on initial visit• Reviewed and updated with subsequent visits• Promotes accurate diagnosis

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LO 7.2 Building an Office Visit Note

• Objective components of Office Visit– Vital signs– Examination

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LO 7.2 Building an Office Visit Note

• Other components of Office Visit– Medical diagnosis– Medications

• Epocrates Website• Drug interaction/allergy alerts• SureScripts Web-based e-prescribing clearinghouse

– Tests– Procedures– Other treatment– Follow-up/Reminders

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LO 7.3 MODIFYING THE OFFICE VISIT NOTE

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LO 7.3 Modifying the Office Visit Note

• Modification of OV note– Allows various disciplines to document during one

encounter– Entries initialed – Permanently signed and locked at end of

encounter

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LO 7.4 CREATING AN ADDENDUM

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LO 7.4 Creating an Addendum

• Once permanently signed and locked – no changed to office visit

• Addendum– Allows for entry of information after the fact• Clarification• Addition of inadvertently omitted information