the key to maintaining a complete record of patient/nurse interactions
The nursing note is designed to maintain a complete record of the interactions between the nursing staff and the patient.
For example, when a patient calls the office and talks with the nurse about a medical problem, the nurse can call up the patent's emr on the computer at the nurses' station. The nurse can then review the record and discuss the problem with the doctor. The instructions given to the patient can then be recorded as a nursing note from the nurse's terminal. It is important to note that this common type of interaction has been accomplished without pulling a patient chart--or having to re-file a chart.
This feature is designed to assist the nurse in the processes of contacting patients for specific follow-up.
An example would be, if a small child, with a high fever, is seen by the physician on Tuesday afternoon, the doctor may want to have the nurse contact the patient's parents the following morning to check on the child's condition. To facilitate this close follow-up, the "Nurse Call-Back" flag is set at the time of progress note entry. The following day, Pal/Med will automatically remind the nurse to check on the patient.
This feature addresses two vital concerns of the physician--quality of patient care and malpractice risk management. In addition, the "extra mile" is usually sincerely appreciated by the patient.
The Treatment Note utility is designed to maintain a complete record of interactions between office staff member and the patient. These notes could reflect a cast change or physical therapy treatment, for example. The doctor may also find this utility helpful for recording after hours or week-end treatment notes from a home computer.
Copyright 2011: Pal/Med Development. Electronic Medical Record Software. All rights reserved.
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