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Chapter 11
Nurse Note DocumentationLevel 3
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill
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Chapter 11 Content
LO 11.1 Teaching (Patient Education)LO 11.2 EvaluationLO 11.3 ReassessmentLO 11.4 F/U-REM (Follow-up Reminders/ToDo
List)
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LO 11.1 TEACHING (PATIENT EDUCATION)
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LO 11.1 Teaching (Patient Education)
• Patient education– Key intervention for nursing – SpringCharts has specific area focused on
documentation of instruction• Intervention component of SOAPIER
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LO 11.2 EVALUATION
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LO 11.2 Evaluation
• Evaluation– Patient progress toward meeting outcomes must
be evaluated routinely • Determine if nursing interventions are effective• Determine if outcomes have been met or if the plan of
care requires revision
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LO 11.3 REASSESSMENT
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LO 11.3 Reassessment
• Reassessment– Response to intervention• Analgesic• Diuretics
– Post-procedure• Surgery• Heart catheterization
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LO 11.4 F/U-REM (FOLLOW-UP REMINDERS/TODO LIST)
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LO 11.4 F/U-REM (Follow-up Reminders/ToDo List)
• Follow-up reminders– Allows nurse to set reminders for follow-up care– Useful for discharge disposition
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