A Reflection Of Dealing In A Patient Note Writing

Clinical documentation Improvement (CDI) is the program or the training that is design to provide the good link between coders and health care providers that increase the accuracy and completeness of patient health care documentation. According to American Health Information Management Association (AHIMA) tool kit CDI is the program especially design for health care field for initiate concurrent and, as appropriate, retrospective review of patient health records for accurate, incomplete, or nonspecific provider documentation (Scharffenberger and Kuehn 2011). Most of the time patient health record review occur in inpatient location but it there is any confusion then the review can go through electronic health records too. CDI play a vital role solving complex case between coder and health care provider that result in easy and smooth operation of reimbursement process in health care organization for the service they provide to patient.

Last week Thursday on the orthopedic clinic was a slow but eye opening experience. When I got to the clinic at 8AM, after I was introduced to some of the nurses there, I was immediately assigned to a Medical Assistant (MA) that I had shadow for half of the day. The MA shows me around the clinical and explained her role and responsibility in the clinic setting. During the first several hours, and MA and I were quite busy rooming the patient. Because the MA want me to see how to do thoroughly assessment on a new patient, the MA did a thoroughly assessment and examinations on the first patient we saw. During the assessment, the MA also explained some of the medical procedures to the patient. She did a set of vitals on the patient, particular on new patient, such as blood pressure, height, and weight. We had a total of 15 patients during the morning.

The last week of classes for NURS1005 were a series of clinical skills activities. These activities refreshed the student’s minds on what they will be doing on placement and how to do it. We got assessed on three clinical skills; taking and recording vital signs, blood glucose levels and doing a urine analysis. I’ve chosen to reflect on taking vital signs and how I performed them. Reflection is a very important part of learning from experiences which is essential in nursing. Nursing practises continue to change and it is easier to go with and to add to that change if you are reflecting on your practise. This essentially makes nursing practises better for the patients. I have reflected on the process of how I took the vital signs during my clinical skills activities. I was very nervous but believe I performed them well due to how I was taught, what I have read and seen and the vital signs signified how my peer was acting which was healthy and within a normal range. Even though I felt I did them well, there were improvements that could and have happened since. Most of the improvements are minor in comparison to the strengths I have but it is important to recognise improvements when needed so you are giving the best and accurate care. I was aware of these improvements needed and tried to strengthen them during my clinical placement which helped me learn different ways of doing processes and also the rationale behind the processes.

My practice in nursing has been influenced by various elements within my career. I have come to embrace that nursing is a learning process and one should expect constructive criticism. When I began as a “novice,” I found myself nervous in some clinical situations but I managed to remain focused on

The patient is a 12 year old female who presented to the ED with thoughts of self harm and cutting behaviors. The patient denies suicidal ideation, homicidal ideation, and symptoms of psychosis. The patient reports that she has been sad lately. Per- documentation the patient reports to peers at her school that she was trying to kill herself, which the school sent her to DayMark. Further, Daymak IVC the patient and requested further evaluation.

As I entered Mrs. Brown’s room I introduce myself, my role and the reason of being there and asked her how she would like me to address to her. Being supervised by the RN I asked for an informed consent prior to commencing a focused holistic assessment and then I asked what would be a good time for me to come back. I did recall from a handover that Mrs. Brown has a Clexane which

In this assignment I am going to deliberate the care of a patient that I have looked after when working in placement on a hospital ward .I will use the Chapelhow framework to discuss two of the perspectives in relation to the patients care needs. In the Chapelhow framework there are six perspectives that are used to help reflect and discuss patient care. These six perspectives are assessment, communication, documentation, risk management, professional decision making and managing uncertainty(Chapelhow, 2005).The two perspectives I am going to use in this assignment are assessment and communication.

Third week into clinical. So far, things are slowly improving, however I do need to work on critical thinking and being less task oriented. I had my very own patient. The clinical objective was to be able to perform a successful health assessment on a patient and to identify factors in the environment that would impact patient care. Hopefully from there, my critical thinking skills will develop through experience and to fill my concept map thoroughly. On Tuesday, my patient was an older gentleman who came in with destruction of the liver due to medication. When caring for my patient, I made sure that he received everything that he wanted. I felt that I did well in that aspect for seeking good for the patient. I was told to get his good and make his bed. I don’t know why making his bed didn’t occur in the beginning. But, I learned that in the beginning, it’s important to make sure that the environment is clean, their bed is made, and ask if they needed a show. The important thing that I received from this is asking yourself what would you want the nurse to do if you were the patient. One thing I do realize is that my ability to work with patients and communicate with them with some baseline knowledge is good. With these, I am able to be more confident in my work. But, I do need to work on looking at the full picture when gathering information from the patient. I tend to overlook things but I will improve by realizing my failures.

It is my belief that every patient, regardless of the severity of their condition/presenting complaint deserves my undivided attention and I am also aware of the importance of ‘getting right’ those first crucial moments of a consultation. How the patient is greeted, patient comfort and environment all shape the patients first impression and help to develop communication and rapport (Egan, 1998).

The last visit I had with the patient on June 7th, I elected to start him on antihypertensive therapy. He was given a prescription for Zestoretic 10/12.5 mg one p.o. to take daily. He says that he did take one as recommended. That same day in the afternoon, he noted that he was short of breath in the afternoon. He says that he attributed it to the work that he was doing out in the yard and later that day, it seemed to resolve. A few days later, he had the same thing happen again. He eventually went on to see Dr. Lilly on June 25th. Please see that note for complete details. She did have him go through a series of testing, including laboratory studies, which were normal

I grew up listening to these words over again, until they became a part of me. As the oldest, it was my responsibility to take care of my younger brothers when my parents were on call. Our apartment in Toronto was opposite the hospital so this happened quite often. My parents' lives as doctors seemed like rollercoasters that never came down. They always had fascinating stories to tell, as well as interesting patient profiles. Sometimes, my mom took us to work. Her office always intrigued us, especially because the hallway had motion sensor lights that we'd never seen.

A twist on the "patient's perspective" approach is to describe a time when medicine failed to save or heal someone close to you. The purpose of this tactic would not of course be to rail against the medical profession, but rather to show how a disappointing loss inspired you to join the struggle against disease and sickness.

As a student of nursing program I am doing 220 clinical placements at True Davidson long term care. On the first day of my clinical, I was so excited and quite nervous too. On that day, I picked one patient and it was my first experience to handle the client individually. I am going to write about that I eventually learn something from my first clinical experience. My buddy nurse told me to go to client’s room and ready her for breakfast. Then, I went her room and said her to be ready for breakfast. She looks at me and seems angry. At that time my mind was wandering that what I did mistake to her. It was the fifth week of my 220 placement, however, that event has left a permanent effect on my mind and it comes to my mind on every

Today I had a great day at the clinic. For the morning section, I had Omar Lora as my patient. Last time when he came, I collected all my assessment data. Today I updated his medical history, dental history, vitals, and EIOE, then I completed filling out the gingival assessment, the treatment plan, and the SAOP. Finally, I was ready to have my assessment data checked. It went really well, and I learned ways to helped me be more efficient with my time management, for example, I did not know how to have my radiographs up in the other monitor while I was doing my assessments. It was a little time consuming having to open and minimized the window every time I needed to look at the radiographs. Also, I discovered that having a piece of paper out and taking

In just one day the average person will speak approximately 16 000 thousands words - I know what you’re thinking, that’s a lot of words right? Yet, what if I told you that those words only make up a small part of our day-to-day communication? Good morning class. So much of our communication happens outside of just what we say, it happens through how we say it, when we say it, what our bodies are doing and in many more ways. Today we will be taking a look at the communication between a nurse and a patient and examining some of these verbal and nonverbal aspects of communication. Specifically we will be discussing the nurse’s tendency to avoid the patient’s concerns, as well as her poor speech delivery and how the two affect the nurse’s ability to assist her patient.