Week 5 DQ 1 22 hours ago 1 reply Corina Gozzip Last 19 hours ago I believe that any company’s medical records are organized and stored in a manner that allows easy access. At a minimum, medical records must be maintained for at least 11 years. Here is the order that I prefer to follow: • Keep a unique, individual record for each patient. Establish an organized record keeping system to ensure that medical records are easily retrievable for review and available for use when needed, including at each patient’s visit.…
Author: Wentworth Laura, Diggins Jennifer, Bartel David, Johnson Mark, Hale Jim,Gaines Kim Title: SBAR: Electronic Handoff Tool for Non Complicated Procedural Patients. Journal: Journal of Nurse Care Quality Year: 2012 Volume: 27 Issue: 2 Pages: 125-131 Purpose and/or Problem Statement:…
This means they are taken via the mouth, in the form of a tablet, capsule, liquid or suspension. These medicines come in a variety of shapes and sizes, colours and tastes. Solid dose oral formulations are made either as tablets or capsules, and are formulated to aid compliance and reduce adverse effects. As well as tablets and capsules, oral medicines can also be delivered by liquids, suspensions and syrups. Again, these are formulated to aid compliance.…
Concerns or issues that the PA feels the primary physician should know are written down. This allows the two to work together in order to provide the most effective care for the patient. During the examination the PA may learn the patient’s height and weight as well as any other basic information needed. They will also talk to the patient to find out more detailed information about the problem the patient is having, this information is then put into a clinical SOAP note. The note has four sections including subjective, objective, assessment/problem list, and plan3.…
The patient must be given information on the medications they should be taking when the patient is discharged from the hospital. The Rosa Parks Wellness Institute for Senior Health (RP-WISH) created a program that focused on improving the safety of care by making an increased effort to schedule follow-up appointments and medication reconciliation within 1 week of discharge. They wanted to make this program because the RP-WISH office manager wanted clinical pharmacy specialists and inpatient pharmacists to be directly involved with medication reconciliation which they were never part of before. The plan was to help in care transitions in regards to medications by reconciling patients’ home medication use with primary care and hospital records (Liu & Garwood, 2015). They intended to call patients that were discharged home when the pharmacy finds medication-related problems and to intervene to resolve those problems to avoid adverse drug effects.…
“When designing screens in an information system application, the data elements on the screen should have a logical flow and design. The screen should follow the traditions left to right and top to bottom formatting. The screens should be designed with the needs of the user in mind, providing instructions to the user where needed to facilitate data quality and data collection. There should also be consistency throughout all of the screens with regards to terms uses, abbreviation, and overall look and feel of the system” (Sayles & Trawick, 2014, p.107). Following the entire above guidelines, I will develop date entry screens for the admission, triage nurse, and medication order entry.…
Giving the patients the proper information about the medication administered must be included when recording medication in the patients chart. The medical assistant may first start off by given the patient verbal information about the medication administered. The medical assistant can offer the patient printed information about the medication that was administered and the reason why it was administered. It is also required that the provider provide the patient or parent of a minor with written information prior to an immunization, this is require by the (NCVIA) National Childhood Vaccine Injury Act of 1986. If any variance where made this should also be noted, such as the patient refused to take their medication or the medication was administer…
It is the most feared mistake of a nurse: a medication error resulting in the death of a patient. The article, "Lesson from Colorado: Beyond Blaming Individuals” by Judy Smetzer identifies fourteen system failures which led to the death of an infant. By explaining each of the fourteen failures, Smetzer explains how such a grave mistake is not the fault of a single person or a single component of a system, but the fault of the systems collectively. Two of the system failures identified, incomplete clinical information and conflicting information on intravenous use of milky white substances, contributed significantly to the error. Several precautions need to be instituted to avoid a repetition of these system failures in the future.…
My clinical experience so far has been quite interesting, because I learned basic clinical procedures and preventions that I know will benefit me as a nurse in the near future. During lab, we discussed infection control, personal hygiene, and isolation precautions. These procedures impact my personal health and wellness, because I need to ensure that I am using the proper techniques in order to keep me safe. Also, I know that it is important to make sure my patients are not at risk of developing hospital associated infections.…
The pain began slowly, pricking me with its sharp needles only while doing barre in ballet once a week. I ignored it, believing it to be normal, common discomfort that would soon go away, typical thoughts of a dancer whose entire sport is centered around “good pain”. Six months later, it had escalated to the degree that every step I took felt like an arrow to my knee. Dancing had become impossible, and it was determined that I should be taken to the orthopedist. The bland, brown and beige lobby became extraordinarily familiar as I waited two hours to be examined.…
Physically, I would describe my body as medium and heavy. Medium because I'm not that tall and also I'm not that short. I see myself in the middle. Heavy because I have experience some gain during the past three months since I have overly been going to the gym.…
At the beginning of my nursing career most of the medical terms I’ve come to use and understand I had while little knowledge about. Some of these terms I picked up in practical experience and other I learnt in lectures. One of these terms has come to be very important in my nursing career and that is medication management. At first my understanding of this concept was very limited and I didn’t understand many of the different factors that all came together to make up the whole. Over my studies this understanding has evolved and become a core part of my nursing practice.…
Foundation of Knowledge model Discharge Summaries relate to Electronic Health Records Nursing informatics is a specialty involving knowledge and technology. According to McGonigle and Mastrian, The Foundation of Knowledge model is a “framework for examining the dynamic interrelationships among data, information, and knowledge used to meet the needs of health care delivery systems, organizations, patients and nurses” (2015). The Foundation of Knowledge model includes acquired knowledge, disseminated knowledge, processed knowledge and generated knowledge.…
Medication Reconciliation in the Hospital Setting The transition of patients from an acute care setting to a home setting is often challenging and stressful. It can be complex for the patient to understand the instructions for discharge and, more importantly, it can be challenging and dangerous when it comes to ensuring the patient understands the medication reconciliation process. Successful transition to home is multifaceted and depends partially on an accurate and complete overview of all medications with the patient. This is an imperative safety measure across the continuum of care (Ruggiero, Smith, Copeland, Boxer, 2015).…
This memorandum gives guidance on how to properly ensure the safety of every patient of this clinic and what to inspect to avoid hazard throughout this facility. As nurses and assistants, everything you do should be revolved around the patients, their safety, and what the best way is to take care of them. To do this it is important to get a proper history of the patient when they are first admitted. For example, be conscientious of the different types of medication they brought with them and be aware of the different types of medication they had previously been on. If necessary, contact their general practitioner and get a summary of their previous care.…