Assessment is a systematic process using a rational method of planning to identify a patient’s health and any actual or potential problems that need to be met and to provide interventions to meet those needs. (Berman et al, 2010) A comprehensive assessment establishes a database of information relating to the patient including visual observations during initial interview including, skin condition, cloths, hair, hygiene, demeanor and presence of pain etc. During the interview the nurse should gather family history and both subjective and objective data to establish baseline data as a reference point and an indicator to the effectiveness of interventions. (Berman et al, 2010) Subjective data is what the patient thinks, feels and believes and can also be referred to as the symptoms including itching, pain and worry or anxiety. Objective data is measured during the physical examination; it can be seen, heard, smelt, felt, observed, tested or measured against an excepted standard, including: skin color, bowel sounds, blood pressure, temperature, level of pain, urine analysis etc.
Introduction Healthcare coding personnel use information provided in clinical notes from healthcare providers in order to convert this information into a code. Coders will review the information provided in health records to identify diagnoses and procedures, in order to “translate” this information into an appropriate code. Healthcare coders must have training in medical terminology, diseases, injuries and healthcare procedures in order to ensure accurate translation of medical notes into these codes (Grain and Hovenga. 2011). The use of coding schemes (such as ICD-9) allows for consistency in documentation between different healthcare providers.
Individual Health Records • What different forms are used to keep patient information? What is the purpose of each form? Inside a patient’s medical chart there are many different forms that contain vast information concerning that specific patient. Each individual record will have a patient history form, which helps the physician, nurses or medical provider to better understand any past and hereditary illnesses, past surgeries, past injuries, and past pregnancies of a patient. This helps reduce the chances of providing unnecessary treatments or tests on a patient, and helps in diagnosis of a patient.
Assessment Tool Analysis Paper Assessment tools are used to evaluate and help with the intervention of a patient’s physical, mental, and emotional well-being. They enable medical practitioners to help the vulnerable make informed and appropriate choices for a normal life. Assessment tools can be useful in improving family dynamics, building more cohesive relationships, and promoting healthier lifestyles. There are many different types of assessment tools, some are more effective than others and it is the responsibility of the practitioner to determine the tool that best fits the dynamics of their patient's particular situation. Jean Watson is recognized for her theories on human caring and the way nurses give care.
Evaluate How Policy Drives Patient Safety The aim of this essay is to evaluate how health policies drive patient safety, with a specific focus on policies relating to hand hygiene in health care. The essay explores the legislative framework, guidelines, and range of policies evident, and the degree to which these policies are successful in reducing Hospital Acquired Infections (HAIs). The essay references a number of Acts, policies and guidelines from the Department of Health, World Health Organisation and NHS Trusts. Health care policy can be seen as a network of interconnected decisions, plans and actions which collectively form a strategy or approach in relation to practical issues relating to the delivery of health care and the improvement of patient safety’ (Barker, 1996, p6). Improvement of patient safety consists of evaluating how patients may be injured, deterring and managing risks, recording and investigating incidents, learning from such incidents and implementing solutions to reduce the possibility of them reoccurring (Great Britain.
Running head: NURSING SENSITIVE INDICATORS 1 Nursing Sensitive Indicators Organizational Systems and Quality Leadership RTT 1 Task 1 August 29, 2014 NURSING SENSITIVE INDICATORS Nursing Sensitive Indicators To analyze the given scenario one must first have a foundational understanding of what nursing sensitive indicators are and how they could have been used to significantly improve patient care. Next the analysis will determine how the hospital will use these indicators to improve overall patient care. The analysis will conclude by identifying specific resources that could be used to resolve the ethical issue in this scenario. It wasn’t until 1996 that the term Nursing Sensitive Indicators was used. Nursing sensitive indicators are by definition,” elements of patient care that are directly affected by 2 nursing practice.”(American Sentinel University - Healthcare, 2011, para.
Prevention of illness and injury, refers to metaparadigm of health and illness, which describes the client’s state of well-being. Alleviation of suffering through the diagnosis and treatment of human response, describes the metaparadigm of nursing, which refers to the actions taken when providing care to the patient. Advocacy in the care of individuals, families, communities and populations, describes the metaparadigm of person which refers to recipients of nursing care which includes individuals, families and
Its objective is to provide statistical cost related data from both internal and external entities. (Moran & Shajahan, 2008, p.45). HIPAA Privacy and Security: HIPAA was developed to administer patient confidentiality and security. Its objective is the continuation of patient support and privacy that can be strictly enforced with the hospitals standard policies and procedures. (Moran & Shajahan, 2008, p.45).
The Caldicott Report set out general principles which should be used by health and social care organisations when reviewing use of service user information. Information: to share or not to share – Caldicott2 Review (2013) The Caldicott2 Review looked into the balance between protecting patient information and its sharing, to improve patient care General Medical Council – Confidentiality: Protecting and Providing Information (2009) The document outlines the parameters of a doctor’s duty to protect patient confidentiality. It highlights issues like: patients’ right to confidentiality; protecting information; sharing information with patients; the circumstances under which disclosure of information may be made (e.g. with the patient’s explicit or implied consent; those dictated by law; and disclosures in the public interest); disclosure after a patient’s death; and disclosure in relation to treatment sought by children and those who are mentally incompetent. NHS Code of Practice.
Name: Topic: Reflective Essay Tutor: Date: Introduction Comprehensive Health Assessment is a successful clinical system usually used to provide comprehensive medical history for patients. The information collected becomes stored in one essential location for easy access in the future (Lenox (2007). Furthermore, a comprehensive health assessment is a process of steadily collecting and analyzing data to be used in making important judgments about patient’s health and other life processes for individuals and families. It includes critical analysis of data in order to come up with diagnosis and to recognize mutual problems. Health assessment plays a major role in the identification of individual’s strengths so that they are assimilated into healthcare planning.