...Instructions Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report. Abbreviation | Letters Represent | Context Definition or Application within the Patient’s Chart | Source Document | 1. ICD | International classification of diseases. | States the classification of coding use | Admission SummarySheet | 2. CM | Clinical Modification | Classification of coding use | Admission Summary Sheet | 3. N/A | Not Available | This information concerning the patient is not available | Admission Summary Sheet | 4. ER | Emergency Room | States where the patient was taken for medical care | History & Physical | 5. C/O | Complains of | She made complain of | History & Physical | 6. SOB | Shortness of breath | Symptoms she was having | History & Physical | 7. mg | Milligram | The dosage of medication used | History & Physical | 8. po | By mouth | Method the patient will take her meds | History & Physical | 9. tid | Three times a day | The amount of times the patient will take...
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...Advanced Generalist: Reaction Paper In today’s society nursing has grown to fit the healthcare needs of society. We have grown by providing different nursing educational roles that will evolve healthcare as we know it. The advanced generalist education role is a clinical nurse leader. The American Association of Colleges of Nursing defines the clinical nurse leader role (CNL) as a leader in the healthcare system that delivers care across different settings within a Microsystems, using assimilation and application of research-based information to design, implement and evaluate the patients plan of care (Thompson, and Lulham, 2007). The Clinical Nurse Leader is further described as designing and implementing, and evaluating client care by coordination, delegation, and supervision of the care provided by the health care team (Thompson and Lulham, 2007). Thompson and Lulham (2007) states that the healthcare team in which supervision care is provided from the CNL include the license nurses, technicians, and other various health care professionals. American Association of Colleges of Nursing (2013) states that clinical nurse leaders are masters prepared nurses that involves risk anticipation for individuals and groups of patients, implementation of evidence based practice initiatives, team leadership, management and collaboration with other health care professional team members, and the use of information system and technologies to improve healthcare. The advance generalist advocates...
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...whether daily videotelephone or regular telephone reminders would increase the quantity of prescribed cardiac medication taken in a sample of elderly individuals who have congestive heart failure (CHF) (Peteva, 2001). Within this research I would disseminate the new scientific knowledge with the help of the pharmaceutical company that makes the congestive heart failure medication. With the help and support of the pharmaceutical maker, I would provide a full in-service to the nursing staff of hospitals and doctor’s offices alike. In doing this, this would provide a friendly and educational atmosphere in a nursing practice setting to get complete understanding of the research findings and how they as nurses can make a difference in the consumption of prescribed medication. Secondly, I would write a journal article and have it published in the pharmaceutical’s bulletin to include a well-known nursing journal. These journal articles would contain the findings of the research and suggestions on how the nursing staff can help the patients improve the compliance of taking prescribed medication. Once the information is disseminated into the medical public, the nurses will apply the learned knowledge to their practice for the elderly patients who are taking congestive heart failure medication. First, the nurse will collect all the patients that are currently taking congestive heart failure medication and explain to them on a one-on-one basis the benefits of having reminders to comply...
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...Nursing informatics is defined as “the integration of nursing, its information and information management with information processing and communication technology to support the health of people worldwide”. Nursing informatics has applications in different areas of administration, education, and clinical information. It can also assist vendors to create and implement better solutions goaled at improving the care of patients. At my place of employment, the informatics phenomenon known as “Healthstream” is utilized. This system was set in place to enhance continuity care of patients, manage information related to the nursing process, and has become an essential component of providing quality healthcare. One way that informatics allows nurses to provide more patient care is by decreasing the amount of time spent on documentation and searching for data (i.e.. lab results, recent service rendered, last pain level and the care that was provided to decrease it). Another way informatics aide in increasing the quality of the patients care is by ensuring that every healthcare member is up on the patient’s progress. This is valuable when determining a safe discharge plan so that every member of the health team can read progress notes and add the knowledge they have toward making sure there is no recurrence of the patients illness. It also assists us nurses in teaching, lower chances of medicine mishaps, and providing competent care based on religious beliefs of the patient. Resources: ...
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...Communication is a key skill for any health care professional, but for nurses, we ‘are in an occupation that has interpersonal communication at its core. Virtually all nursing work revolves around the need for nurses to be effective communicators, whether relating to colleagues or with service users. (Morrall 2001). This essay seeks to discuss an evidence based experience learnt in clinical practice. For the purpose of this essay the author has chosen communication skills, since it is the basis for which verbal, non verbal and written ideas are conferred among the nursing staff. Some key policies and evidence taken from (research evidence or from this essay) will be identified and discussed. It also seeks to conclude with a general analysis from the overall main findings of this essay. The National Midwifery Council (NMC) (2008) state that nurses must take part in appropriate learning and practice activities that maintain and develop their competence and performance. As a nurse in training, I had been given the opportunity to complete a four weeks placement in a rehabilitation unit. The services provided included the admission of patients requiring rehabilitation therapy and specialist nursing attention. I was elected by my mentor to sit in their weekly review meeting consisting of the Multidisciplinary Team (MDT) in order to facilitate my learning objectives. As a student my role was to observe how the MDT addressed, planned and implemented patient care. This was necessary...
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...whether daily videotelephone or regular telephone reminders would increase the quantity of prescribed cardiac medication taken in a sample of elderly individuals who have congestive heart failure (CHF) (Peteva, 2001). Within this research I would disseminate the new scientific knowledge with the help of the pharmaceutical company that makes the congestive heart failure medication. With the help and support of the pharmaceutical maker, I would provide a full in-service to the nursing staff of hospitals and doctor’s offices alike. In doing this, this would provide a friendly and educational atmosphere in a nursing practice setting to get complete understanding of the research findings and how they as nurses can make a difference in the consumption of prescribed medication. Secondly, I would write a journal article and have it published in the pharmaceutical’s bulletin to include a well-known nursing journal. These journal articles would contain the findings of the research and suggestions on how the nursing staff can help the patients improve the compliance of taking prescribed medication. Once the information is disseminated into the medical public, the nurses will apply the learned knowledge to their practice for the elderly patients who are taking congestive heart failure medication. First, the nurse will collect all the patients that are currently taking congestive heart failure medication and explain to them on a one-on-one basis the benefits of having reminders to comply...
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...School of Nursing NURS 220 Spring 2016 Vocabulary Homework Assignment – Chapters 10-16 in Taylor et al textbook – Worth 100 points Chapters 10 – 13 due Thursday February 25 Chapters 14 – 16 due Thursday March 3 Please define the following words using your Fundamentals of Nursing textbook and/or a medical dictionary. Please indicate the text and page number you used to obtain each definition. (If you want to make them flashcards you may, just make sure that your name is on them and they are rubber banded together so I can record and return them easily.) Chapter 10 Assess Concept mapping Decision making Dynamic Evaluate Expected outcomes Implement Interpersonal Nursing diagnoses Nursing process Outcome identification Outcome oriented Plan Reflective practice Systematic Cerebral Vascular Accident (CVA) Chapter 11 Cue Data Data base Documentation Emergency assessment Focused assessment Inference Initial assessment Interview Minimum data set Nursing history Objective data Observation Physical assessment Review of systems (ROS) Subjective data Time-lapsed assessment Validation Multiple Sclerosis (MS) Prioritize Factual Accurate Relevant Interpersonal competence Virus Consultation Laboratory study Diagnostic study Chapter 12 Constipation Cancer Actual nursing diagnosis Collaborative problems Data cluster Diagnosing Diagnostic error Health problem Medical diagnoses Possible nursing diagnoses Risk nursing diagnoses ...
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...Home Health Chart Audit Review-Report 2011 GRANT/CATRON COUNTIES | |1st Q |2nd Q |3rd Q |4th Q | |60 day cycle sheet (in chart & frequencies consistent w/Dr.’s orders) |Met |Not met |Met |Not met | |60 day cycle sheet (in chart & frequencies consistent w/Dr.’s orders) |Met |Not met |Met |Not met | 60 day cycle sheet (in chart & frequencies consistent w/Dr.’s orders) |Met |Not met |Met |Not met |Met |Not met |Met |Not met | |a. Skilled nursing | | | | | | | | | |b. Physical therapy | | | | | | | | | |c. OT | | | | | | | | | |d. MSW | | | | | | | | | |e. HHA | | | | | | | | | |Original Intake in chart | | | | | | | | | |Initial Assessment-completed w/I 48 hrs after referral or discharge from referring facility | | | | | | | | | |Face to Face ‘s –effective 4/1/20 | | | | | | | | | |HABN’s | | | | | | | | | |BIPPA’s | | | | | | | | | |Medicare secondary payer worksheet- completed, signed, dated | | | | | | | | | |Consent for treatment- completed, signed, dated | | | | | | | | | |Privacy notice acknowledgement- completed, signed, dated | | | | | | | | | |Financial responsibility & insurance verify. | | | | | | | | | |Written 485-completed & signed by clinician | | | | | | | | | |Witten 485-goals signed off | | | | | |...
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...Task 724.4.2-01-05 Discuss an original presentation to introduce the new EMR system to staff on you unit. In your Presentation: 1. Discuss how access to information is important to the delivery of nursing care, specifically how the EMR system will benefit nurses in their work with Pt’s. Hello everyone. My name is John Smith. I am a RN here at the Hospital and I am the Director of Nursing Informatics. As I’m sure all of you know to be successful in the care of our Patients you have to work as an interdisciplinary team and timely COMMUNICATION is key! As you can see I have capitalized communication to emphasize how important it is. As a Nurse on the unit a big part of communication is reporting a patient’s condition after you have assessed and treated them. This is not only done verbally be talking to the Attending MD, Consulting MD’s Patients and their Family members, but also documenting this in the Pt’s legal medical record. Without effective, accurate and timely documentation of all aspects of a Patients care by the multiple disciplines taking care of the Patients you can have severe consequences including and up to death of the patient. I’m here to discuss the implementation of the EMR system we will be going live with next month. For those of you who don’t know what EMR stands for it means “Electronic Medical Record”. I do not want you to feel intimidated by having to use a computer for those of you who don’t use one often or at all. We will be training all of...
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...Four-Year Degree Becoming A Must for Nursing Candidates falseNewman, Richard. The Ledger [Lakeland, Fla] 22 Apr 2012. Turn on hit highlighting for speaking browsers Abstract (summary) Translate AbstractUndo TranslationTranslate Press the Escape key to close From[pic]To[pic] Translate Translation in progress... [[missing key: loadingAnimation]] The full text may take 40-60 seconds to translate; larger documents may take longer. Cancel "Honestly, I don't expect it to be easy," said [Corynth Torres], who is scheduled to graduate from Bergen Community College's two-year nursing program in May. She plans to take the state examination for certification as a registered nurse soon afterward. Torres said nursing "seemed to be the right choice" because it offers the best opportunity for steady employment, good pay, flexible hours and advancement. However, competition is stiff because the number of nursing graduates has risen and older nurses are delaying retirement in an uncertain economy, leaving fewer openings. Another barrier for many graduates is employers are more insistent that nurses hold four-year degrees. "New graduates are having trouble for the first time in a long time," said Sharon Zaucha, associate dean of nursing at the community college. "The enrollment trends are still very strong, but there are not a lot of jobs for entry-level registered nurses," she said. "Honestly, I don't expect it to be easy," said [Corynth Torres], who is scheduled to...
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...health, various institutions strive to improve service care through highlighting different methods that can be incorporated to improve the particular sector. This has subsequently led to the idea of outcome management being included in various health institutions. In equal measure, the proper outlining of the above-mentioned aspect about the nursing profession plays an imperative role in factoring the patient who in turn helps substantiate this particular perception. It also proves essential to take note that outcome management also provides evidence-based information which is used in evaluating its current progress which in turn helps different institutions come up with better strategies that will help improve the quality of services offered. The patient The term patient refers to the individual that receives medical services from healthcare providers. Typically, multiple patients have a wide array of expectations and preferences during the process of being treated. Outcome management creates an environment upon which several patients can have a platform that they can use to give information which in turn is used to measure progress. Information gathered from patients in different healthcare facilities is acquired through studies such as Hospital Customer Assessment of Healthcare Providers and Systems. Additionally, questionnaires are equally issued with the aim of receiving information from the said clients. During such studies, patients get to give their opinion on a wide...
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...Charting / Documentation Guide Nursing documentation should be clear, timely, accurate, reflective of observations, permanent and legible. This is a guide and not a complete list. Always follow policies in place at your facility. Medicare Documentation • Must reflect need/reason for skilled care • Must reflect Standard of Care • Describe intervention(s) • Describe resident’s response to intervention(s) • Daily evaluation of progress or lack of progress • Resident response to skilled therapy • ADL function • Changes in condition • Change Care Plan ASAP after change in condition • Notification to MD and family Respiratory/Pneumonia Medicare Documentation • Must reflect need/reason for skilled care • Daily vital signs • Daily and PRN O2 sat level • Daily and PRN lung sounds • SOB with exertion, when sitting at rest or when lying flat • Resident’s response to interventions and skilled therapy • Progress or lack of progress • Change in condition • Change Care Plan ASAP after condition change • Notification to MD and family Bladder and Bowel • Indicate status: always continent, occasionally incontinent, frequent- ly incontinent, always incontinent • Indicate if has catheter (indwell- ing or condom, intermittent), uri- nary ostomy, or no urine output • Toileting program in progress or attempted and outcome • Constipation? Which interventions used, and results? Anticoagulant Therapy Medicare Documentation...
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...Nursing Assessment & Diagnosis | Planning & patient centered goals | Nursing Interventions | Scientific Rationale | Evaluation | 1) Diagnosis: Excess fluid volume r/t decreased urinary output Assessment: B.K is an 88 year-old female presented with acute renal failure with urinary retention. Patient was admitted into Lehigh Regional on July 5th, 2013.Previous history: Diabetes, HTN, UTI, skin cancer, TIA. Subjective: Patient states, “I feel a bit fatigued in the evenings. My doctor said it is a side effect of my dialysis sessions. I don’t like going to dialysis but I know that I have to”.Objective: Patient alert and oriented x4. Vitals signs: BP: 119/72, Temperature: 98.9, Pulse: 82 bpm, respiratory rate: 18, and displays no pain at this time. Breath sounds clear, gag and cough reflexes intact. Bowel sounds present in all four quadrants. Eyes: PERRLA. Skin integrity is not intact; stage 1 pressure ulcer located in right posterior upper thigh, below buttock. Minor bruising on both upper extremities, No signs of DVT. Patient PICC line placement in right upper arm. Patient is easily fatigued primarily after dialysis sessions. Chooses to ambulate by wheelchair due to occasional dizziness. 1 assist when walking.Diagnostic test: Recent CBC done on 07/11/13 showed an elevated WBC count with a result of 14.0.Progress notes: “ Patient readmitted to facility due to noncompliance with dialysis sessions. Experiencing fatigue and occasional anxiety between dialysis sessions. Recent...
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...incorporated and collaborative team working addressed. The Department of health (2002) describes discharge planning as a pathway used to decide patient needs, for a smooth move from one level of care to another (Hunt 1996) and is the process through which patient’s needs are identified and plans are written, facilitating continuity of health care (Jackson 1994). According to the department of health (2000) discharge planning illustrates well, the role of the nurse within the inter-professional team the balance between goals set, care delivered and evaluation of care from a nurse and team perspective. Nurse involvement is considered integral and, aims to provide effective discharge plans (Department of Health 2000). The Royal College of Nursing (RCN 2002) supports the concept of nurses taking the lead and recommends the development of nurse led protocols in discharge planning. However the NMC (2004) highlights the importance of nurses being able to integrate within the team, seeking advice and sharing knowledge where appropriate. Effective and ineffective communication will be addressed, using the Victoria Climbie Report (Laming 2003) to highlight poor team communication. Effective discharge planning seeks to maintain the benefits of rehabilitation after the patient has been discharged from hospital (Department of Health 2003)....
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...What is a Nursing Home? Nursing Homes are places for people who don't need to be in a hospital but can't be cared for at home, more commonly referred to as skilled nursing and rehab centers. Nursing care is typically provided for people who need long-term care or rehabilitation after surgery or are recovering from a more severe medical condition like a stroke. These communities provide all of the personal care and services of an assisted living with the addition of 24-hour nursing care. Regent Care Center Facts Funded 35 yrs ago A modern facility with 180 beds Joint commission accredited facility A for profit-non-sectarian, and private funded organization Client Population: mostly 65 and over Catchment area: Includes many residents of Bergen-Hudson-Passaic County. Also patients from Hackensack Medical Center Regent Care Mission Statement Regent Care Center’s mission is to provide the best possible quality of care and quality of life for our long-term residents and sub acute patients. We are also committed to improving quality of life for our staff and family members of our residents. All staff, through team work and the interdisciplinary process, will provide the highest quality service compassion and respect to residents and their family members. The staff of Regent Care Center fulfills its mission and produces a first-class facility by practicing the key concepts on a daily basis: C= Commitment to residents, families, self, and career L= Leadership – setting a...
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