MN566 Unit 2 Discussion Essay
What does it means to document accurately and appropriately?
According to (Mathioudakis, Rousalova, Gagnat, Saad, & Hardavella, 2016), high quality clinical notes detail the medical history of the patient. The quality of our record keeping is a reflection of the standard of care we give to our patients. Well documented, and precise patient records is the emblem of a caring and conscientious nurse, but below par documentation can lead to uncertainties about the nurse’s ability. The nursing documentation is where what nursing care the patient gets and the patient’s reaction, in addition to any further outcomes or issues that may influence the patient’s wellbeing. Document the rationale for your diagnosis and treatment.
What are the documenting guidelines? When is it appropriate to use abbreviations?
Using SOAP format. Accurate records will contain observations of clinical outcomes. Every single submission into the medical record should be signed, timed (24 h clock), dated and legible. The Joint Commission offers direction to practitioners on safe medication practices through its “Do Not Use” list of abbreviations. To avoid misinterpretations and possible danger to the patient’s wellbeing, MOI.4 calls for all hospitals to have in place a record for accepted as well as, do-not-use abbreviations and check for proper abbreviation use (JCI, 2018). MN566 Unit 2 Discussion Essay
What is the difference between subjective and objective data?
(Lew & Ghassemzadeh, 2019) noted that subjective information is what the patient tells the provider such as the history, from chief complaint through the review of systems. Objective data all physical exam findings that the provider discovers through exam. Symptoms are the patient’s subjective depiction and ought to be documented under the subjective heading, while a sign is an objective finding related to the related symptom stated by the patient. MN566 Unit 2 Discussion Essay.
What does it mean to demonstrate clinical reasoning skills?
Clinical reasoning skills will help the provider make a pertinent and proper conclusion intended at prevention, diagnosis, and treatment of a patient’s problem. Clinical reasoning involves the ability to critically think. Clinical reasoning, also known as clinical judgment, is the process by which clinicians collect signs, process information, understand the patient’s medical situation or problem, plan and implement appropriate medical interventions, evaluate outcomes, and learn from this entire process (Benner, Hughes, & Sutphen, 2008).
How can you use clinical reasoning to plan the organization of a comprehensive exam?
Intuition, cognitive Skills and Critical Thinking Skills. Being able to think critically and using the clinical reasoning processes that uses hypothesizing, hypothesis testing, re-analysis and differential diagnosis. Collaboration with the patient a significant part of the clinical reasoning practice in producing positive outcomes (Atkinson & Nixon-Cave, 2011). MN566 Unit 2 Discussion Essay
How will you document variations of normal and abnormal assessment findings?
You will document both normal and abnormal values as well as if the abnormal value has been chronic. Develop action plan/management plan once the problem has been identified for the abnormal values. Document referrals whenever appropriate and necessary. Responsiveness to decision making and follow through is also imperative (Dunphy, Windland-Brown, Porter, & Thomas, 2015).
What factors influence appropriate tools and tests necessary for a comprehensive assessment?
Diagnostic hypothesis can use screening methods such as diagnostic test to confirm or rule out a condition (Dunphy, Windland-Brown, Porter, & Thomas, 2015). A comprehensive health assessment contains an examination of social and behavioral influences, epidemiology, health risks and data from the patients and/or families/caregivers. I will look closely at relating data such as age, gender, and health insurance, and examine the problem list, the medication list, and facts such as the records of allergies. The chart frequently offers important information about past diagnoses and treatments. MN566 Unit 2 Discussion Essay.
Reflect on personal strengths, limitations, beliefs, prejudices, and values.
My growth in the profession of nursing has been a process that has been enriched through the experience, education and my training that I have had. Knowledge gained from advanced practice courses will also help me to possess a grounded understanding of normal physiologic and pathologic mechanisms of disease that serve as one primary component of the foundation for clinical assessment, decision making and management and will provide me with a deeper understanding of fundamental theories and concepts in pharmacology that are directly applicable to advanced practice nursing.
How will these impact your ability to collect a comprehensive health history?
Courses in clinical practice will provide me as an advanced practice nurse with the tools to perform a comprehensive health assessment on clients across the lifespan. I will build my knowledge of anatomy, physiology, pathophysiology and health assessment skills previously attained in my undergraduate nurse education and recent graduate courses. These diagnostic reasoning skills are needed for clinical reasoning in the advanced practice role as I will be able to identify effective and ethical interviewing techniques, document the findings of a comprehensive health assessment and physical examination of my client and integrate those assessment findings into recommendations for health improvement.
How can you develop strong communication skills?
Active listening skills are important but sometimes overlooked, as they can become less sharp over time. I fosters a work environment that consists of open communication, trust, leadership, professional development, and excellence in customer service, shared decision-making, whenever possible, and role clarification. As a leader I must also support the processes that facilitate effective collaboration.
What interviewing techniques will you use to interview the patient to elicit subjective health information about their health history?
Before I begin talking with the patient, I will clarify goals for the interview. I will balance provider-centered goals with patient-centered goals. MN566 Unit 2 Discussion Essay. I will use sound critical thinking and clinical decision making to develop a comprehensive data base, including complete functional assessment, health history, physical examination, and appropriate diagnostic testing that will allow me to develop an effective and appropriate plan of care for the client which takes into consideration life circumstance and cultural, ethnic, and developmental variations.
What relevant follow-up questions will you use to evaluate patient condition?
According to (Dunphy, Windland-Brown, Porter, & Thomas, 2015), AHRQ inititaves promote effective guidelines to investigate outcomes and evaluating response to care. The follow-up evaluation is a crucial step in the care process. The follow-up evaluation reinforces your commitment to your patient, supports the therapeutic relationship, and validates your willingness to work with your patient to attain the preferred objectives of treatment.
How will you demonstrate empathy for patient perspectives, feelings, and sociocultural background?
I know that by just listening I can help the person identify and express their feelings and cope with the situation. I learned that motivational interviewing is a powerful strategy to apply in my practice. To help cultivate empathy, begin with self-examination. Self-awareness includes knowing one’s personal biases, values, desires and concerns which may affect our interactions with others. As a nurse I must be sincere and really care about what happens to others. This is the root of my role as patient advocate. Also cultural competency and safety is an area that must be focused on to help build and establish the patient relationship (Hamric, Hanson, Tracy, & O’Grady, 2014). My personal belief system has always been to be compassionate and caring. In the nursing profession you need to have a vast amount of compassion and caring for your patients and their families. You are not only caring for the patient’s physical health, but also their emotional needs. I believe a collaborative partnerships allows the provider to distinguish what is truly important to the patient’s health. As an Advanced Practice Nurse I must understand the patients’ and families’ fears and their coping skills, I need to understand their intention and respond to challenging situations without losing my connection with them.
What opportunities will you take to educate the patient?
Any and every opportunity available about health promotion, new medication, new or current disease processes, disease management. MN566 Unit 2 Discussion Essay.
Atkinson, H. L., & Nixon-Cave, K. (2011). A Tool for Clinical Reasoning and Reflection Using the International Classification of Functioning, Disability and Health (ICF) Framework and Patient Management Model. Physical Therapy, 416–430.
Benner, P., Hughes, R. G., & Sutphen, M. (2008). Chapter 6 Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In P. Benner, R. G. Hughes, & M. Sutphen, Patient Safety and Quality: An Evidence-Based Handbook for Nurses (p. Chapter 6). Rockville: Agency for Healthcare Research and Quality.
Dunphy, L., Windland-Brown, J., Porter, B., & Thomas, D. (2015). Primary Care: The Art and Science of Advanced Practice Nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.
Hamric, A., Hanson, C., Tracy, M. F., & O’Grady, E. (2014). Advanced practice nursing. An integrative approach (5th ed.). St. Louis, MO.: Elsevier Saunders. MN566 Unit 2 Discussion Essay.
JCI. (2018, March 30). Use of Codes, Symbols, and Abbreviations. Retrieved from Joint Commission Internation: https://www.jointcommissioninternational.org/use-of-codes-symbols-and-abbreviations/
Lew, V., & Ghassemzadeh, S. (2019). SOAP Notes. StatPearls, 13-15.
Mathioudakis, A., Rousalova, I., Gagnat, A. A., Saad, N., & Hardavella, G. (2016). How to keep good clinical records. Breathe, 369–373. MN566 Unit 2 Discussion Essay.
In healthcare, it is important to adopt and initiate new practice, ideas, and research into our daily process. APRN’s exert considerable time and energy on a daily basis disbursing interventions to improve well-being and in the long run, the patient’s experience. Management of any medical problem is a multifaceted process, which is greatly aided with a healthcare partnership. Preventative care is significant to all health care (Merzel & D’Afflitti, 2003). The Nurse Practice Act (NPC) holds each individual nurse accountable for the quality of nursing care provided and sets forth minimum standards of practice to which nurses are expected to apply and include into their daily practice (National Council of State Boards of Nursing, 2018). MN566 Unit 2 Discussion Essay.
Merzel, C., & D’Afflitti, J. (2003). Reconsidering Community-Based Health Promotion: Promise, Performance, and Potential. American Journal of Public Health, 93(4): 557–574.
National Council of State Boards of Nursing. (2018, April 12). Nurse Practice Act, Rules & Regulations. Retrieved from National Council of State Boards of Nursing: https://www.ncsbn.org/nurse-practice-act.htm
I enjoyed reading your post! Nilsen, (2015) stated that strong, open communication across teams strengthens the chance of firmly embedding change by supporting the development of therapeutic relationships and removing barriers. Good communication is a prominent piece of every phase of the change development and almost all researchers cite it as fundamental to effective implementation. MN566 Unit 2 Discussion Essay Clinicians dedicate a great deal of time to determining diagnoses for illness or abnormalities that their patients are suffering from.
Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science Journal, 53-57.
The nurse practice act is a guideline that governs nurses through their scope of practice, education standards, licensure requirements, and varies from state to state (Nursing: Scope and Standards of Practice / Edition 2, 2010). Discovering methods to handle ethical conflicts is perilous not only to the distraught clinicians but also to organizations struggling to progress outcomes, as moral distress can poorly affect patient care. Support the nursing code of ethics. Westrick (2013) stated the ANA Code of Ethics gives the framework for practice MN566 Unit 2 Discussion Essay.
Nursing: Scope and Standards of Practice / Edition 2. (2010). Nursesbooks.org.
Westrick, S. J. (2013 ). Essentials Of Nursing Law And Ethics. Burlington, MA: Jones & Bartlett. MN566 Unit 2 Discussion Essay.