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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
• 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
• 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
• 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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