Sample Medical Review Audit

The assessment process is the back bone to any package of care and it is vital that it is personal and appropriate to the individual concerned. Although studies have found that there is no singular theory or understanding as to what the purpose of assessment is, there are different approaches and forms of assessment carried out in health and social care. These different approaches can sometimes result in different outcomes.

Nugent, W., Sieppert, J., & Hudson, W. (2001). Practice Evaluation for the 21st Century. Belmont, CA: Wadsworth.

Evaluation of a patient’s outcome, to determine the effectiveness of the treatment that they received while under my care, is

Assessment is the initial stage of the nursing process. Roper et al consistently use the term ‘assessing’ to signify that it is an on-going process, and highlights its continuity throughout the patient’s episode of care (Aggleton & Chalmers, 2000). It is divided into two stages to allow for a holistic representation of the patient to be established (Barrett et al, 2009). Effective assessment allows the prompt identification of any changes in a patient’s health status, and if necessary; allows any action to be carried out immediately supporting the delivery of safe, effective care DH (). The formulation of an accurate assessment is a fundamental skill for a student nurse as outlined by the NMC (2004), and so it is important that a holistic approach is adopted for this skill to be achieved. An holistic approach supports the consideration of……..needs,(THEME?) which

Any re-assessment is conducted as soon as practicable after you have been informed of the requirement to be re-assessed and have been given the opportunity to be re-trained and assimilate the training. You are re-assessed in only the areas

Assessment in the nursing process will establish the patients' ongoing needs and provide a quality of care best suited to the individual, to achieve a desirable health outcome.

Refinement “which” is the action of receiving electronic receipt for high quality standardized performance measurement data and covers every aspect of care delivery.

The documentation did not support the need for an evaluation of a stable, chronic wound.

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

Finally, the intervention must be evaluated for effectiveness. If the intervention fails to achieve the desired outcome, then the process returns to the fourth step and the selection process for the next intervention is initiated. (Kozier, Erb, Berman, & Burke, 2000, p.261)

Prior to the actual treatment, the patient is given general anesthesia and a muscle relaxant. Electrodes are then attached to the patient's scalp and an electric current is applied which causes a brief convulsion. Minutes later, the patient awakens confused and without memory of events surrounding the treatment. This treatment is usually repeated three times a week for two to four weeks. The number of treatments varies from six to twelve. It is often recommended that the patient maintain a limited intake of medication, after the ECT treatments, to reduce the chance of relapse.

The second argument for the use of ECT is that successful treatments induce remission in episodes of illness (Gabbard, 2001). The evidence supporting this conclusion is compelling and includes a sizable number of well-controlled “sham-ECT” studies. In these studies, patients were randomized to receive real ECT or sham-ECT (which involves anaesthesia but no electrical stimulation), thus providing for precise double-blind tests of efficacy (Gabbard, 2001). One misconception is that it provides a “cure”. This is not the case - it does not produce a “cure” any

Assessment is described as”The first stage of the nursing process, in which data about the patient’s health status is collected” (Oxford dictionary of nursing, 2003, p23), following this phase a care plan can be devised.

If an evaluation of this program were to be performed, it would be requested by administration. Administration in this agency includes, but is not limited to the president and vice president of the agency, an executive program director and his/her assistant, and a small panel of developmental board members. Staff members at Eskenazi Health would find the feedback from the evaluation beneficial, as they can use it to better the care and

A re-evaluation is scheduled 4 to 6 weeks after scaling and root planning for patient’s that are a calculus class III or class VI. The purpose of a re-evaluation is to compare the results from the previous appointment and to determine what improvements need to be made in the treatment plan for that specific patient. A re-evaluation is specified to 4 to 6 weeks after scaling and root planning in order to allow the gingiva to heal and for the clinician to be able to assess the oral hygiene status. The first step at a re-evaluation is to perform a medical history review for any changes in medications or medical alerts. Blood pressure and pulse will also be taken at the re-evaluation to evaluate changes from the appointments before. After the medical