* Assess patient’s pain level and administers appropriate pain relief measures. * Maintains patient’s safety(airway, circulation, prevention of injury) * Administer medication, fluid and blood component therapy, if prescribed. * Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy. 2. Identify priority nursing care to prevent potential complications following this type of surgery.
A series of education training of documentation was implemented to help reduce episodes of Medicare payment denials and self-protection through adequate documentation. Thus, I will discuss the impact of inadequate nursing documentation that leads to malpractice lawsuits. Purpose of Medical Record Documentation Understanding the purpose of medical documentation was the first step in teaching how to prevent inadequate documentations that leads to liability and malpractice lawsuits. Monarch (2007) supports the purpose of Medical Record Documentation as the following: • Substantiating the health condition or illness or presented concern for the patient. • Effective communication among health care staff.
11/12/2012 Components of a Nursing Care Plan A nursing care plan is a set of guidelines that directs nursing activities for a patient. It details the entire steps needed from beginning to end of a patient’s care. The nursing care plan is also a framework that allows for evaluation of the effectiveness of the plan and it promotes continuity after the patient has left the healthcare facility. The four main components of a nursing care plan are: nursing diagnosis; expected outcomes; interventions; and evaluations. Documentation of the nursing care plan is important in order for the patient to receive proper care.
The structure indicators are related to nursing staff characteristics such as the skill mix, experience, certification and education of the nurses. The process indicators are those that measure the interactions of health care personnel and the patient such as nursing assessments and interventions. Moreover, RN job satisfaction falls under the process. Nursing Sensitive patient outcomes are the desired or undesired changes that are impacted the most by nursing care such as patient falls and pressure ulcers. Nursing-sensitive indicators are important to use to achieve optimal nursing care.
The inpatient coder ensures that the data entered is relevant, indicating the reason that the patient was admitted, which involves the kind of illness and a breakdown of the treatment that was given (Henderson.) The inpatient coder uses the current version of ICD-CM classification for the most appropriate DRG assignment for assigning codes to diagnoses and procedures. They have to be able to determine the correct diagnosis and secondary diagnosis, identifying and assigning co-morbidities and complications and principle procedure codes. The inpatient coder is also responsible for selecting the proper DRG and Discharge Disposition Code. The impatient coder sends the documentation to HIM Operations for follow-up when Physicians documentation is not clear or straight forward.
History taking is a competent skill which enables practitioners to make accurate diagnosis and this skill is a fundamental requirement for the code of practice to maintain professional accountability (Nursing and Midwifery Council (NMC), 2010). Using a structured approach to guide the process can help the health professional to develop their skills in time management during the consultation and assessment. This ensures that the time a nurse has with the patient is used effectively and important elements are not missed (McEwen and Harris, 2010). Practitioners ‘must’ be apt in taking an accurate history from a set format ensuring that questions are pertinent to the diagnosis stated Crumbie (2006). In this case, the patient presented with a productive cough lasting over two.
First, the RN needs to collect the data. Collecting data includes doing a thorough medical history along with listening to the client/family members and observing the client. Once the data is collected, it must be organized, validated, and then documented. In the case of John, the objective data is what the nurse observes, and data collected. This includes information such as John's shortness of breath per his nasal cannula and breathing treatments.
RTT1 Organizational Systems and Quality Leadership Task 1 WGU ALLEN SMITH A. Understanding Nursing Sensitive Indicators Nursing sensitive indicators include the configuration, process and outcomes of nursing care. The configuration of nursing care concludes the nursing staff, their nursing skills, and the level of education that each nurse holds. The process of nursing care concludes the nursing assessments, intervention and implimentation. The outcome of nursing care either positive or negative depends on the quantity and quality of the care provided to the patients by the nursing staff ("Nursing world," 2013) Each nurse should hold proper information and knowledge of nursing care such as knowledge of pressure ulcers.
Introduction Communication is an important aspect of nursing practice; it’s the activity of conveying information through the exchange of thoughts, messages or information through speeches, body language, writing or signal. “Basic communication skills include the use of clarification, reflection, probing, summarising and open questions.” (Doughterty et al, 2004). The following is a personal reflective assessment of my communication skills with a patient; my self assessment on my performance of the conversation will be discussed under the following four headings; initiating the session, eliciting the information, therapeutic relationship and closing the session. ` Initiating the Sessions It’s important the nurse bring a friendly atmosphere to the room and introduces herself to the patient, while maintaining patient privacy.I entered the room slowly as I felt nervous but I happily greeted the patient with a hand shake which demonstrated my professional courtesy and introduced myself as a nursing student. I closed the door behind me to maintain privacy.
Another strategy I used was to approach a situation from more than one point of view, think through problems thoroughly, assess and investigate a problem or situation, implement good use of the nursing process in all situations. An example of thoroughly assessing a problem is, in a situation where you find an oriented head trauma patient with a sudden change in mentation. Before calling the doctor, I would first of all assess orientation, any changes in pupil size; do a set of complete vital signs. Today, I can freely say that my nursing career has evolved tremendously from an occupation to a skilled