A Patient 's Care Recommendations

The purpose of this paper is to conduct an in depth exploration of the nursing care considerations of patients in a specific clinical area. Through the synthesis of prior knowledge, clinical experiences and skills, evidence based best practices, and care of patients a comprehensive care and teaching plan will be composed. Integration of critical thinking and clinical reasoning skills, combined with evidence-based research will provide confirmation of nursing process comprehension. The inclusion of reviewed literature will further support knowledge and understanding.

Health history of a patient is an important tool in identifying health issues and devising efficient interventions to address them. Hence, health providers can use health history information to diagnose, treat and plan for the care of the patients (Ball et al., 2006). In that light, we will focus on the patient named BB for purposes of privacy and confidentiality. BB is a 70-year-old Caucasian female. The patient resides and recently just moved to Show Low, Arizona. She is married and operates her business with the help of her husband. The interview was conducted at her home in Show Low, Arizona. More importantly, the patient's consent was sought before this meeting and she was assured of the confidentiality of the information shared

Within this case study I am going to use two of the Chapelhow et al. (2005) enablers to discuss and reflect on the care of a patient I have been involved with on placement over a period of 5 weeks. ‘Enablers are the essential and underpinning skills that come together to provide expert professional practice’ (Chapelhow, C et al. 2005, p.2). These include; assessment, communication, documentation, risk, professional decision making and managing uncertainty. The enablers work together to provide a holistic approach to the care of patients in health care settings. I am going to focus on and discuss two of the enablers, linking them both together, which will be assessment and communication as I believe these two enablers can be related most to my patient.

6. Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate

There will be information at hand to assist in making medical decision during the time of visit. Lastly, the EHR mandates that people’s health information is to be kept secure ("Department of Health and Human Services," 2008).

When patients are brought back for rooming, the nurse or medical office assistant will review the printed list with the patient prior to documenting in the EMR. During the office visit, we will review polypharmacy and are adding a document to our resources section of the EMR regarding polypharmacy and accurate medication list that will be given to all patients. I have always been aware of the importance of accurate medication list, but was not reviewing this often enough in our patients EMR.

ANSWER: The type of information that is gathered is marital status and/or living arrangemet, current employment, occupational history, any use of drugs, alcohol and/or tobacco, level of education, and sexual history. These questions are relevant just incase the lifestyle the patient is living has contributing factors of the patients illness. This will provide more information and can assist in the diagnosis.

Include documentation in nursing flow sheet, nursing notes, or physician orders. Documentation should be accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes.

These systems will also help cut down on medication errors by comparing the patient’s to medications or interventions so that it is given to the correct patient. Also documents the care given so there would be no human error in the case of questioning whether care had been given as long as the caregiver documents in the record. These features of the electronic health record are in place to promote patient safety by reducing errors.

This information is important when counseling individuals so that we don’t violate the patient’s privacy. Patients may disclose protected health information such as medical issues and medications during interviews or while filling out paperwork. Knowing that sharing this information is a HIPAA violation and has legal ramifications can save us from a lot of unwanted trouble. Also, knowing this will allow us to take extra care not to leave documents such as files or paperwork laying around that contains patient information. It allows us to know not to discuss with others, what a patient discusses with us. This information informs us of who we are allowed to share this information with. Sometimes it might be necessary to share information with a patient’s doctor in order to coordinate treatment or other services. In addition, it might also be necessary to speak to the patient’s provider about any food / medication interactions or possible food intolerance /allergies. It is also important to know for billing

Over the course of decades medical treatment has advanced causing an increase in the wellness of patient clinical outcomes. A large portion of the improvement is due to the vital role nurses play in the delivery of safe and quality care to their patients. For many years different methods of treating patients have evolved due to the continued research for the best practice. Nurses, researchers and people with questions have always tried to find better and efficient solutions to treat their patients detailing the best possible evidence-based practice. Evidence-based practice is an important tool to use for clinical decision making however one must understand it first. Interpreting Evidence-based practice allows nurses to comprehend the steps to determine if new evidence is needed and realize there are some benefits to utilizing up to date research and obstacles that may impeded the research into practice. .

Individuals need specific care tailored to them, it is vitality important to have the correct professional and appropriate personal care. In order to receive this we need to get the patient involved in the decision process, listen to their views and opinions and receive the relevant, accurate, professional and medical information. Once all the information is collaborated a personal care package can be put into practice.

From information contained in the patient’s social services, medical, and legal records, the clinician is able to piece together Mr. Y’s history.

Case management in the emergency department, constantly works to find the right data in a patient’s record to ensure that they have the correct insurance coverage and can be admitted or discharged at the appropriate time and place. Even when the smallest amount of essential information is not documented, this otherwise straight forward process turns into a scavenger hunt for who has seen the patient, interventions that were done and for what reasons, and at what time all of these things took place. ED case manager Veronica Kountz (personal communication, March 20, 2015) states that the inadequacy of documentation can lead to insurance companies not covering patient costs, which the hospital then has to absorb. Before a patient can be admitted or discharged, the right

Clinical practice guidelines (CPG) are designed to improve the quality of healthcare services, decrease unwanted, ineffective and harmful interventions for patients. CPG are used to facilitate treatments for each individual patient’s by maximizing the benefits, minimizing the risk of harm and obtain treatment with an acceptable cost. Researchers had proven that CPG is a bridge for change and improving health outcomes. The effectiveness of CPG is perceived to be helpful in clinical decision making. CPG are developed to assist healthcare providers such as doctors and nurses in decision making for specific clinical outcomes (Vlayen, et. al. 2005)