Shadowing Use In A Patient's Room

Improved Essays
The language with which the healthcare workers use in their notes is one that takes an individual to decipher. As an intern at the Emergency Department of the Johns Hopkins Hospital, I got to witness many patients coming in with diverse needs and in turn observed the method of notetaking nurses that I had the opportunity to shadow use in recording the complaints of the patients.
When I shadowed a nurse in the Emergency Critical Care Unit, she displayed the electronic medical records on the computer screen after visiting a patient's room. I observed her as she added more comments on the progress of the patient. While she was typing I made an effort to decipher what she meant by terms like I&D by recalling all the medical terms and abbreviations

Related Documents

  • Improved Essays

    Hcr 220 Week 3 Essay

    • 471 Words
    • 2 Pages

    If I go into a EHR of a patient who has just transferred to my facility, I should be able to read it and know exactly what action was taken in regards to care of the patient. The continuity of care will not be interrupted if we all use a standardized language. If nursing languages are not standardized across every nursing practice a barrier may exist when exchanging information with important health information being missed. It is also important for accuracy of the nursing records.…

    • 471 Words
    • 2 Pages
    Improved Essays
  • Improved Essays

    This paper is all about physician assistants and what they do for the medical field. Starting with who physician assistants are and what they do. Then this paper discusses what kinds of writing is involved with physician assistants. Patient notes, drug orders, and journals are just a few writings physician assistants must do. The writings must be written in a certain way in order to have a consistency in the medical field.…

    • 1031 Words
    • 4 Pages
    Improved Essays
  • Decent Essays

    This is a biannual event which I am able to attend only the events in October. On October 2015, I volunteered as a dental assistant in restorative dentistry where I assisted other volunteer dentists in amalgam procedures. On October 2016, I volunteered as a volunteer sterilizer, where I utilized my multi-tasking ability to ensure dentists have clean instruments available at all time. The speed and efficiency of the entire clinic depend on our work and preparations as a team. Both years were two days shifts, including optional shadowing that I participated before my actual shifts.…

    • 187 Words
    • 1 Pages
    Decent Essays
  • Decent Essays

    With everyone always being so busy these days even the patient's the Dr., nurses, and even pharmacist need to pay close attention to what they write and what is being…

    • 102 Words
    • 1 Pages
    Decent Essays
  • Improved Essays

    Research for Evidence-Based Nursing Practice Outline In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed in efforts to modernize and use health care technology in a meaningful way (Huryk, 2012). As a result, there has been a dramatic shift in the way nurses care for patients at the bedside. With the introduction of the electronic health record (EHR), bedside nurses have been challenged with adopting new technology and workflows.…

    • 656 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    Marissa and Amber both work at Aurora St. Luke’s Medical Center in Milwaukee, Wisconsin. They both work in the medical field, however Marissa is a Certified Nursing Assistant (C.N.A.) who is currently working full time and Amber is a Registered Nurse (R.N.) who is currently working part-time and attending school to get her Master’s Degree to become a Nurse Practitioner. Written communication is imperative in their workplace. Although they were both unaware of how often they actually use written communication, we were able to uncover many different ways they use it on a daily basis through an interview. Marissa, C.N.A. at Aurora St. Luke’s Medical Center:…

    • 1205 Words
    • 5 Pages
    Improved Essays
  • Improved Essays

    My first though on this assignment was “ Who writes anymore? With all of the technology we have no one writes anymore,” I was wrong. I frequently find myself writing at work, at Intermountain Medical Center as a Patient Care Tech and as a Health Unit Coordinator. Often I am writing for myself, writing to my coworkers, other departments in the hospital and writing for as well as to my boss. Recently I noticed the longer I have been working at this job the more comfortable I am writing to my colleagues and my boss.…

    • 600 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    Delegation In Nursing

    • 758 Words
    • 4 Pages

    Effective Delegation Delegation is an essential skill of a Registered Nurse (RN). According to Zerwekh and Garneau (2014), delegation is “the process for a nurse to direct another person to perform nursing tasks and activities.” This definition of delegation is easy to understand, and seemingly a simple concept. However, delegation is anything but a simple task.…

    • 758 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    6. Recording and Reporting (M6) These are the most significant tools required by nurses to be efficacious in carrying out our daily activities in caring for our patients. A report or account refers to a statement which is understandable and a representation of realities concerning an identified matter which principally affords information for sequel arrangements, actions and decision making. Its chief features take account of comprehensiveness, it needs to be prepared in written form, must afford direction and information besides its relevance as a form of tool meant for an internal communication.…

    • 512 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    Gastrointestinal Bleeding

    • 938 Words
    • 4 Pages

    With healthcare being such a rapidly moving field it is important that we, as aspiring medical professionals, understand what is progressing in our profession. Within the blink of an eye healthcare changes; doctors, professors, phds, are coming up new theories, journals and studies daily. It is our job as current students in this field to do our best to further understand these journals studies, etc.and the writing that is involved in our field. Why you may ask? There are arguably an infinite amount of perspectives in the medical field ranging from a vast amount of topics-- understanding how to read and write professional writing based on medicine is imperative for our future careers and their advancement.…

    • 938 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    I find myself frequently writing clinical notes for work. Clinical notes are; medical records where healthcare professionals record details to document a patient's status or achievements during the course of treatment. When writing these notes, I have to make sure my handwriting is legible and what I’m stating is comprehensible to minimize mistakes. I specifically write these notes for dentists or whomever is treating the patient. These are necessary for giving the patient proper treatment.…

    • 162 Words
    • 1 Pages
    Improved Essays
  • Superior Essays

    Increasing Patients’ Perception of Care: An Action Plan Guided by its mission, vision, and values, the strategic planning committee assesses, and develops the overall goals of the healthcare organization’s strategic plan. General information is disseminated to all stakeholders. These are important steps, but without a well-developed action plan, a strategic plan will not come to fruition. At its simplest form, the components to an action plan include: a clearly identified objective; actions needed to achieve the objective; assigning responsibility and time frame for each task; determining the resources that will be needed; and identifying a method for measuring the intended results (Ginter, Duncan, and Swayne, 2013, p. 389). A thorough understanding…

    • 1047 Words
    • 4 Pages
    Superior Essays
  • Improved Essays

    The content presented in class this week focused on the relationship between nurses and caring technology as well as how increased technology use has/can shape care. Much of my personal insight into these topics was provided through the completion of an activity presented in class. This activity involved two people, each of whom played either a nurse or a patient in order to allow for the gathering and documentation of subjective-based patient information. Upon completion, the class debriefed on the pros and cons associated with the various documentation approaches used, which encompassed paper-based, technology-based, and hybrid (i.e. Healthcare providers write the information presented on paper and then transcribe it into an Electronic Health…

    • 443 Words
    • 2 Pages
    Improved Essays
  • Great Essays

    The clinical care is a risk as poor literacy skills can misinterpret the patient’s condition and diagnosis. Having poor health literacy has not only affected the person’s involvement in the health care system, but also the decisions they will be making in their home, workplace and community. The levels of literacy impacts patients on performing tasks such as reading dosage levels and instructions of medication packages, or if people seek screening or diagnostic test instructions become hard to understand and from the practitioner instructions become difficult for them to demand upon. This is why medical funding increases for reasons such as interpreters need to be providing to help translate information from the practitioner to the patient. In comparison to those with adequate health literacy emergency room cost ($108; 95% CI: $62 to $154; P <0.0001) to those with inadequate health literacy, with a differences in total being ($1551; 95% CI: −$166 to $3267; P = 0.08).…

    • 1329 Words
    • 5 Pages
    Great Essays
  • Superior Essays

    Stephen Kim BUSS376 Nov. 18, 2015 Summary: Deaconess-Glover Hospital 1. What has Carter been doing and why at Deaconess-Glover Hospital? John Carter has been observing various workflows and processes in Deaconess-Glover Hospital to apply the Toyota Production System to a health-care setting. First, Carter tried to identify a site that would be suitable for a model line. He examined various areas in the hospital, including the gastrointestinal unit, pharmacy, and the “South-Two” medical-surgical inpatient care unit.…

    • 867 Words
    • 4 Pages
    Superior Essays