Reflection On Discharge Treatment Plan

As part of my Higher National Certificate course in healthcare I am required to provide evidence of achieving the following principle aims in the form of a graded unit;

Good communication with the individual should be enhanced. Both individual and carer must compromise and negotiate to what would benefit most for the individual as long as it is safe. Thorough information should be given and must acknowledge the benefits of their choices. This is a way of recognising rights and choices of the individual. One example is the resident’s choice not to use his/her walking frame. This is one conflict of decision – making. Decision should be tailored to the needs of the resident

The main theme identified in this research focused on the Hospital readmission rate that has gained increasing attention because it reflects the effectiveness of healthcare system performance and the quality of patient care. The five articles studied all highlighted that an effective discharge planning is crucial to improve continuity of care between hospital and home/elderly home so as to improve patient’s health and reduce patient readmission. The themes that emerged described discharge planning in the hospital as pivotal in the continuing care of people who are in need of medical, social and rehabilitation care. Additionally as the needs of patients increase and become more complex, it is also important that an effective discharge planning system should have the capacity to discriminate and respond to different levels of need for coordination and post-discharge care (Central, 2012).

The hospital that I worked for while working as a case manager was not in network with Kaiser Permanente. It was also the time when the hospital started to hire hospitalists to manage patient care while they are a patient in the hospital. It actually worked out because it filled in the gap in patient care. The hospitalists were acting as the patient's primary care provider. Kaiser as with many other insurance have a case manager designated to ensure that the patient is meeting criteria not only for an inpatient hospital stay but for the level of care they are receiving as well such as ICU, Stepdown, or Med-Surg. I would have to give them an updated clinical information daily or every 3 days depending on the severity of illness. As a case manager, I was responsible for discharge planning and I preferred to transfer the patients to

Ms. Conlon applies the nursing process to systems or processes at the unit/team/work group level to improve care. Deirdre has been the primary nurse for 6 hemodialysis patients. She has involved patients and families in monthly interdisciplinary meetings to promote self-efficacy and quality of life. With the help of the interdisciplinary team Deirdre has worked collaboratively to address and reinforce nutritional needs, social/family issues, barriers to care, and safety concerns. All of her primary care patients have maintained a goal of 100% for dialysis adequacy (benchmark is 85%) and a vascular access rate of 100% and dictated by KDOQI standards.

REQUEST, REASON, ISSUES, BOARD TYPE, AND DECISION: The applicant requests an upgrade of his uncharacterized discharge to honorable. The applicant states, in effect, he served for four years in the National Guard and deployed to Afghanistan in 2005 thru 2006. The applicant contends, he enlisted upon redeployment despite having Post-traumatic Stress Disorder (PTSD) symptoms and other medical problems. The applicant states, he requested counseling for his PTSD, instead he received a counseling statement informing him that he would receive an entry level status (ELS) separation with an uncharacterized discharge. The applicant further contends, he was diagnosed with PTSD and rated 40 percent disabled rating by the VA for PTSD. The applicant states, he had held a position as the communications sergeant with the McAllen Police Department after being discharged. The applicant contends, he is an upstanding member of the community has never been in trouble with the law, and this is evidence of his desire to serve. The applicant further contends, he served his country honorably as an infantry Soldier and an uncharacterized discharge for PTSD is wrong. The applicant states, an honorable discharge would do justice for the unfortunate administrative action taken against him in September 2006.

PO is referred to continue chemical dependence treatment at the community agency. PO will need to have a new assessment to determine appropriate level of care. PO is recommended to attend minimally of two self-help meetings per week, abstain from all mood-altering substance, and utilize positive support structure to aim and maintain substance free lifestyle.

Once a resident has improved with their mobility its down to the care staff to help encourage them to continue using this daily life skill by encouraging them to be as independent as possible with things they are known they are able to do reporting any

This case study is about a patient, T.C., who I treated while a physical therapy assistant at an acute rehabilitation hospital. T.C. had terminal spinal cancer and at the time of admission had a fair prognosis to maintain function and strength enough to be discharged to his daughter’s home with home health care and family support, and he wanted to eventually go back to his own apartment. He was using a wheelchair as he was partially paralyzed from the waist down, and was able to use a transfer board to transfer from his wheelchair to bed and back.

Whilst undertaking the initial assessment, I always make sure that the service user is present and make sure that I am talking to them as opposed to about them with a family member or friend that also may be present. If I am doing an assessment with the service user who has Dementia or Alzheimer’s then again, I ensure that I am asking them what they would like, how they would like the care to progress and what they want to achieve from having care works. If they are unable to answer then I will look to the family for guidance, but it is important to make the service involved in their own care planning and assessment process

My level 1 fieldwork II was assigned at Charleston Area Medical Center – Medication Rehabilitation Inpatient Services in Charleston, West Virginia. It was an Inpatient Rehabilitation which provides Occupational Therapy, Physical Therapy and Speech Therapy services. My supervisor is a Certified Occupational Therapy Assistant for more than 3 years. My fieldwork started around 7:45am and ends at 4pm. My supervisor provides me with occupational profile of the patient, diagnosis and the treatment before interacting with the patients. They usually see 3 patients in a day for 90 mins therapy sessions.

I am learning about the significance of being committed to patient care and dedicating your life's work to the betterment of every patient. I possess a strong academic history as well as a willingness to commit my time to uplifting of my community. Even as a student who has had some hiccups academically, I am proving that I can overcome adversity and "keep my eyes on prize". Furthermore, I am devoted to being the future of physical therapy and displaying selflessness, dedication, compassion, distinction and authenticity. I have learned to sympathize and empathize with patients, however, at the same time stand firm in the therapeutic methods that need to be implemented for the patient's

The patient in this particular case study is an adult man of 45 years with Down syndrome and a moderate intellectual disability. This man also has a chronic illness, which is type 2 diabetes. This man lives in a community group home that is staffed by support workers and he attends a disability-specific day program Monday to Friday. This case study will be reviewed from the point of view of the community nurse managing the holistic case needs of this particular patient. Holistic needs involve a number of different considerations, and must include an overall understanding of the patient’s medical needs, as well as his physical and emotional needs. The goal as the nurse will be to develop a holistic care plan, including an analysis of the health challenges of this individual, an analysis of activity and participation using the ICF model, and an overall recommendation for an intervention strategy for the patient. The intervention strategy will include consideration of all the different aspects of this individual’s difficulties and disabilities.

This week’s reflection paper focuses practice-based evidence and the operation of the theoretical framework of person-in-environment as each relates to discharge planning at UMPC Mercy Detoxification Unit (UPMC-MDU).

Using the seven key principles of the hospital discharge process devised by the Department of Health (DH, 2003), this case study will critically analyse the process of an elderly patient who was discharged from a local acute trust. It begins by providing a definition of discharge planning, before providing a brief biography of the patient, including a rationale of why this patient was selected, details of her past medical history, reason for current admission, any issues raised and details of any care provided. Throughout this case study, in accordance with the Nursing and Midwifery Council (NMC, 2008) and the Data Protection Act (1998), the patient shall be referred to as Mrs. Blue to maintain anonymity. Although the