Digital Clinical Experience

Hi Terry. Nice initial post and I enjoyed reading it. I learned to gather my data accurately and perform the head-to-toe assessment thoroughly. The data that we gather during assessment should be factual and complete to provide diagnostic reasoning, decisions, and proper treatments for patients (Jarvis, 2012). I definitely agree with you, the Shadow Health Assessment with Ms. Tina Jones was also my biggest moment from this course. She was surely challenging, but I would say it was worth it. The comprehensive assessment was difficult and I spent hours in order for me to complete the assignment. I enjoyed doing the assessments of each system. I learned the importance of documenting accurately, clearly, and concisely. In addition to that, the

Estes, M. E. Z., Calleja, P., Theobald, K., & Harvey, T. (2016). Health Assessment and Physical Examination: Cengage Learning Australia.

In this discussion board post, I will compare and contrast informatics and clinical informatics. Then I will give two examples of clinical informatics found in my organization that has been found to improve patient care. I will also give two examples of how my nurse manager can utilize data management in order to improve patient care. Lastly, I will discuss why President Bush mandated that all health records be in electronic form by the year 2014.

Another concept that I learned from lecture and SILC lab was how to give a physical assessment and health history. I was able

Hello Frances, excellent thoughts on your initial post. I felt the same way too. I was nervous and overwhelmed when I started this course. I thought my assessment skills were thorough. However, with this course, I realized that I still have room for improvement. I agree it is essential to treat our patients holistically. Nurses must include the patient’s culture and values, family and social roles, self-care behaviors, job related stress, developmental tasks, and failures and frustration of life in their health assessments (Jarvis, 2012). Additionally, The Shadow Health assessment with Ms. Tina Jones was a great learning experience. With Ms. Tina Jones I achieved the course objective of communicating effectively, writing my documentations accurately,

The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001). Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission. They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i.e. psychological state and cultural/social standing

The first examination will be a brief assessment, firstly to make it is safe to approach the

Perform EPIC electronic medical records system investigations and internal reviews to evaluate compliance with applicable laws, regulations, industry codes and/or company policies, including risk assessments.

The initial assessment is the first step of the nursing process. This is where the nurse will collect the patients spiritual, psychological, sociological and physiological status, these would all influence the 12 activities of living (ALs – see Fig 1.). Physical examinations will be done which will include taking blood pressure, respiratory, temperate, pulse, weight, and O2 saturations, further exams can be taken dependent upon illness, such as blood glucose and urine dips, this all creates a baseline for the staff taking care of Jim.

CPOE training program should be as meticulously customized as the CPOE system itself. Initial training must be complete, comprehensive, and specific to your institution. It should include the hospital’s exact order sets, feature actual screen shots, and be developed around the facility’s workflow, essentially imitating a day in the life of the clinician. Persuading busy hospital and community physicians to attend classroom difficult. Online training — accessible to all users at all times from any location with Internet access — solves this problem. Web-based CPOE training can be made adequately comprehensive that some users can do without the classroom experience altogether. The typical workday of an intern in the ED differs substantially from a cardiology resident in the catheterization lab, and CPOE training must be individualized to reflect such differences. Separate Web-based training can be developed for large audience segments, (e.g., emergency department vs. in-patient or adult vs. pediatric) but to accommodate specific individualization, guided practice exercises in a facilitated classroom are required. This generally involves users completing the e-learning in an interactive classroom. Lesson plans include introductory announcements and preliminary teaching, followed by the user/student’s completing recommended e-Learning sections. Guided practice exercises to fine-tune the training are completed in the classroom, but the facilitator is present mainly for questions and guidance. Certification While some hospitals avoid testing physicians for CPOE proficiency, evaluation is desirable to certify competence and confirm the completion of training. Progress checks can be embedded in the Web-based training and administered randomly during classroom instruction. As the CPOE system is brought online, significance shifts from training to support

There are many stories that can get my attention, but the ones that catch it the most are stories about nursing. Maybe it's because I'm perusing a nursing degree and I will love to know everything that can help me to be a good nurse, but also can be because is very interesting to know more about how a story can have a strong influence on nurses. My big question is how is storytelling used in nursing? How nursing education impacted by storytelling ?

Engaging in this assessment with my patient has been very insightful. Challenges occur everyday from the moment we wake up in the morning until the time we get back in at the end of the day, but having a life altering diagnosis adds to the everyday life complexity. The complexity of a muscular diagnosis is a journey most people have not traveled so relating can be difficult. Reflecting on the assessment, I felt well prepared because of the manuals and examples I have used prior to the assessment. The feeling wheel was a great visual tool I used during my assessment, sometimes it can be difficult to describe the feelings I am experiencing during an assessment and this helped with that. The research I have previously done before the

In other words, it can defined also as the series of questions the clinician ask to the client about each organ system or the body part during the first interview (history) and the physical examination to reach to the most appropriate findings about the client’s medical history and presenting illness. Example of the questions: the examiner can determine the history of fatigue, travel to other countries or the environment, any change in the lifestyles, any signs of fever or weight change. Moreover, the clinician can ask about the patient’s family; who live with the patient?, what is the patient’s relation with whom who s/he lives with?, and is s/he happy in his/her family?. Also can ask the patient about his/her hobbies and interest, does s/he have pets, does s/he exercise daily? And so

Ms Sedgewick says that normally, in this type of assessment, a patient’s subjective experience would hold great weight, but in this scenario, the physios have to rely more on objective testing and

These past few weeks of health informatics have brought to light many important aspects of technology within the health setting. My fellow classmates and I have gotten the chance to dig deep and learn about the use of health informatics within evidence-based nursing, methods patient’s use to find health information, online Communities of Professional Practice (CoP), and the use of Electronic Health Records (EHR) in addition to Personal Health Records (PHR). I believe these innovations can be increasingly helpful in the care process, but they are each still accompanied by their own consequences or adverse aspects. Further, it will be my job as a nurse to discuss these innovations with my patients and provide care in a way that will bring to