Nursing Documentation Using Electronic Health Records Information Center: Feature Summary


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Nursing Documentation Using Electronic Health Records

Byron R. Hamilton, Med-Soft National Training Institute
Mary Harper, Western Governors University
Paul Moore, St. John's Hospital

Feature Summary

All chapters & exercises are designed to accompany the Spring Charts EHR software adapted for nursing. Downloads of the Spring Charts software are available with purchase of the text.
SpringCharts can be downloaded to the desktop or a USB drive.
SpringCharts was designed by physicians, this version is dedicated for nursing education and charts using the SOAPIER format. SpringCharts can hold up to 1 million patients.
Exercises are organized into 4 different levels from simple to complex. Level 1 is the simplest and includes exercises that might commonly be used in fundamentals-level curriculum. Level 4 is the most complex with “capstone” style activities.
Level 1 Exercises – The simplest level of exercises. This set includes three different exercises covering practice in the areas noted below across disease conditions of diabetes, CHF, & pneumonia. Students learn: Navigating to the patient’s chart; Changing Allergies, History, and Meds; Starting a new Inpatient Nurse Note; Documenting chief complaint, vital signs, and an assessment
Level 2 Exercises – Three diverse exercises related to diagnoses of COPD, fractured hip, & colon cancer. Covers all of the nursing documentation areas from Level 1, plus: Documenting nursing diagnosis, documenting outcomes, and documenting interventions; Documenting Medical Administration; and Documenting Intake and Output.
Level 3 Exercises – Three individual exercises related to diagnoses of stroke, cellulitis, & chest pain. Covers all of the nursing documentation areas from Level 1 and 2, plus: Teaching Documentation; Evaluation of Outcomes/Interventions; Reassessment; Follow-up/Reminder Functionality
Level 4 Exercises – A comprehensive “capstone”-style exercise related to a diagnoses of biopolar affective disorder. Covers all of the nursing documentation areas from Level 1, 2, and 3, plus: Printing a Nurse Note; Adding an Addendum to a permanently locked and signed Nurse Note.
Instructor Introductory Exercise – A brief but comprehensive 3-page exercise designed to familiarize instructors with the specific features of the Spring Charts EHR software for nursing in an patient-exercise format.

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