What does it mean to document accurately and appropriately

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What does it mean to document accurately and appropriately?

Clear, accurate, and accessible documentation is an essential element. Regardless of the form of the records (i.e. electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals (Mathioudakis et al. 2016). Remember, if you did not write it down, it did not happen. APRN’s should document noncompliance in the progress record, such as the patient not following the medical advise, not taking his or her medications, not showing up to their appoinments with the PCP or specialist. APRN’s should also document any labs or diagnostic results on the note when the patient comes for the results or if they call the patient and give them the results over the phone. Documenting everything about the patient can help prevent any misunderstanding.

What are the documenting guidelines? When is it appropriate to use abbreviations?

As an APRN we can use SOAP, SOAPIE, narrative, and at my facility we use narrative and SBAR especially for telephone encounters. In order to have proper documentation, we must use proper abbreviations, if handwritten it must be legible. At my place of employment, we (nurses, APRN’s, and MD’s) are not allowed to use abbreviations in our documentation. We use electronic documentation and once we are done documenting, whether it is a note or a telephone encounter, the record shows our name, date, and time it was done.

What is the difference between subjective and objective data?

Subjective data is the information from the client’s point of view and it is obtained through interviews. Objective data is what we observe and are able to measure through observation, physical examination, labs and diagnostic testing. Symptoms are the patient’s subjective depiction and ought to be documented under the subjective heading, while a sign is an objective finding related to the symptom that the patient stated.

What does it mean to demonstrate clinical reasoning skills?

Clinical reasoning skills will help the provider make a pertinent and proper conclusion intended at the prevention, diagnosis, and treatment of a patient’s problem. Clinical reasoning involves the ability to critically think. Nurses’ clinical reasoning can be defined as: “…the cognitive processes and strategies that nurses use to understand the significance of patient data, to identify and diagnose actual or potential patient problems, to make clinical decisions to assist in

problem resolution, and to achieve positive patient outcome” (Barken et al. 2017). Clinical reasoning is the sum of critical thinking and decision-making processes associated with clinical practice, where critical thinking is based

on nurses’ careful, deliberate thoughts in different clinical settings (Alfaro-LeFevre, 2013).

How can you use clinical reasoning to plan the organization of a comprehensive exam?

Clinical reasoning goes beyond knowing and thinking; it also involves the process of taking action and applying knowledge in clinical practice.

How will you document variations of normal and abnormal assessment findings?

The documentation of normal and abnormal values is documented in the patient’s chart. Abnormal values are compared with prior results to determine if it is a chronic condition or not. Patient will be referred to appropriate specialist or test will be redone as indicated.

What factors influence appropriate tools and tests necessary for a comprehensive assessment?

Factors that influence appropriate tools and test necessary for a comprehensive assessment includes an examination of social and behavioral influences, health risks and information obtained from the patients. Also, reviewing the last visit or if the patient comes for a hospital follow up, I will review the hospital records. Medications should be reconciled on every patient’s visit.

Reflect on personal strengths, limitations, beliefs, prejudices, and values.

I have grown not only as a nurse but also as a person, through my work experience and education. I believe that my strengths is treating the patients and their family as I would like to be treated. My mom was a physician and she taught us that we must respect every one’s beliefs and that never judge anyone. My limitations would be language barriers because in the area where I live and work the majority of the population is a mixed of Haitians, Chinese, African Americans, and Hispanics.

How will these impact your ability to collect a comprehensive health history?

To be able to communicate with those patients that do not speak English or Spanish, I will use be sure that I have set up a call for the company that we use and will assist to translate and help me obtain a comprehensive health history. We also have a physician that speaks Mandarin and APRN that speak Creole and they will assist with the translation.

How can you develop strong communication skills?

By active listening to the patient or the family member. Also maintain active listening with your coworkers is very important.

What interviewing techniques will you use to interview the patient to elicit subjective health information about their health history?

First, I would introduce myself and explain to the patient and family what I am going to do. I will use open ended questions. I will use sound critical thinking and clinical decision making to develop a comprehensive data base, including complete functional assessment, health history, physical examination, and appropriate diagnostic testing that will allow me to develop an effective plan of care.

What relevant follow-up questions will you use to evaluate patient condition?

A follow-up evaluation is very crucial in the care process. Questions that I would use: How is the swelling today? Did you get the medication ordered (name the med)? Do you still have symptoms? Do you have any pain (where and intensity)? Would be some of the questions that I would ask.

How will you demonstrate empathy for patient perspectives, feelings, and sociocultural background?

Listening to the patient and /or family and allowing them to express their feelings. Letting the patient and/or family from another culture that you are willing to learn and trying not to be disrespectful towards their culture. I have learned from experience that one I speak to one of our Chinese patients or their family that most of them will not look at you and that does not mean that they are not listening, but it is a sign of respect.

What opportunities will you take to educate the patient?

I take every opportunity available to talk to them about health promotion, new medication, new or current disease processes, disease management, it is Flu season and we have the vaccine.

References:

Alfaro-LeFevre R. Critical thinking, clinical reasoning, and clinical judgement. A critical approach fifth edn. United States: Elsevier; 2013.

Barken, T.L., Thygesen, E., & Söderhamn, U. (2017). Advancing beyond the system: telemedicine nurses’ clinical reasoning using a computerized decision support system for patients with COPD – an ethnographic study. BMC Medical Informatics and Decision Making.




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