Result Notes Documentation Process

CURRENTLY

• We are seeing many different methods of documenting lab results that are discussed with patients.
• Many nurses are putting a result note under the provider's result note, without ever making a telephone encounter.
• Other nurses/medical assistants are copying and pasting the result into their telephone encounter.

CONTINUED...

• Some nurses/medical assistants document their patient conversation in a telephone encounter, but have no link to the results discussed.

NEW PROCESS

• From the "results inbox," click on the "result notes" tab. Here you can place a statement such as "please see telephone encounter dated today." This will show that the result has been addressed and tie it to the telephone conversation. Click "OK" to save.

NEW PROCESS CONTINUED...

• From the small toolbar, click "telephone encounter." This will allow a copy of the doctor's result notes to automatically populate into the telephone encounter.

NEW PROCESS CONTINUED...

• Place a call to the patient, indicating in the telephone encounter who you are calling, and which numbers were called, as well as any messages left. Document your conversation in the telephone encounter and close when complete.

WHY THE CHANGE??

By implementation a standardized documentation process...

• We will show constancy which will increase communication between the healthcare team (Steckman, 2018, p. 102-103)

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• We will improve the quality of the electronic health record, requiring less time for other medical personal to determine if results were discussed which will all lead to better patient outcome, all of which are requirements for meaningful use (HealthIT.gov, 2015)

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• Chand and Sarin (2014) discuss the current lack of nursing documentation and inconsistencies, but state with enough effort and money invested, electronic health records can assist in providing high levels of safe patient care.