Clinical Documentation System Excelsior College October 6‚ 2013 Clinical Documentation System Clinical information system (CIS) collects patient data in real time‚ stores healthcare data and information using secure access to the healthcare team. (McGonigle & Garver Mastrian‚ 2012‚ p. 554). The CIS that is used at Texas Health Dallas is CareConnect. CareConnect is used by all of the Texas Health Resources (THR) encompassing 25 hospitals‚ affiliated physician
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Clinical Journal One Milford Regional Medical Center The nursing process is an assessment‚ diagnosis‚ plan‚ implementation and evaluation of our patients. As a practical nursing student this is something we are learning and improving on daily. Assessment is the most important part of the nursing process. This process is becoming clearer every day spent in the clinical setting. The assessment part of the process is done with every interaction of our patients we are taught in school. I thought how
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Patricia Benner is a nursing theorist whose experience with the Dreyfus Model of Skill Acquisition has earned her many awards and honors for her contribution to the nursing profession. In her work From Novice to Expert: Excellence and Power in Clinical Nursing Practice‚ Dr. Benner introduced the concept that expert nurses develop skills and understanding of patient care over time using a sound educational base and having prior experiences(Benner‚ 1982). Her theory proposed that one could learn knowledge
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Clinical Assessment PSY270 June 23‚ 2013 Elizabeth Cole Clinical Assessment Mr. and Mrs. Lawson brought their 4-year-old adopted daughter‚ Clara‚ to see Dr. Mason‚ a psychiatrist. Clara was polite in greeting Dr. Mason‚ but did not smile and kept her gaze down as she took a seat. Mr. and Mrs. Lawson sat next to Clara and began explaining their concerns. They described Clara as a quiet child who has recently begun throwing temper tantrums‚ during which she is inconsolable. Her sleep and eating
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Introduction This first clinical experience has shown me the importance of developing the nursing-patient relationship. Working with school-age children is a very different experience and requires a new set of communication skills that we have not focused on in class. It was an important step to being able to think on my feet and adapt to the situation at hand. These aspects have really helped me understand the unspoken traits of nursing and what will be expected of me. Identify the Developmental
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Reflection Seven Description: After working for nine months in acute mental health settings‚ I was allocated to go to a rehabilitation stream open ward with long-stay patients. Feelings: Initially I found the transition quite difficult as the style of nursing is markedly different in a rehabilitation ward as opposed to an acute ward. I was not confident at first as to what my role entailed on the ward‚ and how to best assist the patients work towards achieving discharge from the ward. I also
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SHC 31: Promote communication in health‚ social care for children’s and young people’s settings Unit reference: J/601/1434 1) Understand why effective communication is important in the or setting 1.1) Identify the different reasons people communicate People communicate to others for all kinds of reasons. Sometimes this can be essential ‚ such as lifesaving situations or to reach out and make contact with others through sharing various types of information. People communicate
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NEED some quotation marks here…. Clinical Definition According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV)‚ A client must meet the following criteria to be classified as having PTSD: Criterion A: Has been exposed to an event involving threatened death or injury‚ during which the individual responded with panic‚ horror‚ and feelings of helplessness. Criterion B: Re-experiences the event in the form of dreams‚ flashbacks‚ memories‚ or unrest at being in situations that remind
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Clinical Trials ‘All patients should receive the best possible therapy AND the well-being of the individual research subject must take precedence over all other interests.’ Says article 11.3 of the ‘Declaration of Helsinki’‚ the Holy Grail for biomedical research on humans. With more and more clinical trials being conducted in developing countries‚ the question naturally arises…while outsourcing these trials‚ are the pharmaceutical companies growing to disregard this declaration? To be able
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Clinical Session 1 Critique of Clinical Session The clinician begins the clinical session by welcoming Terri and thanking him for coming to the session. Throughout the clinical session the clinician positioned herself so that she was facing the client but still kept her body at a slight angle so that she was not directly across from him. I noticed that their bodies were in close proximity and that their knees were almost touching. The helper made sure to keep eye contact throughout the session
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