Clinical documentation improvement (CDI) “...is improving the quality of documentation to help ensure an accurate and complete reflection of the patient’s care‚ comorbid conditions‚ and treatment- which impacts severity of illness (SOI) and risk of mortality (ROM)” (Custodio et al.‚ 2013‚ p. 56 ). This is an important topic for health care facilities and physicians to ensure it is done well so that the quality of care‚ reimbursement and financial aspects are correct. “There are several other factors
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Clinical Reflection 1. Recall the activity‚ idea‚ or event that gave you the most intense learning “high”. What was it about this situation that was so exciting or pleasing? Working with actual patients is completely different than studying at the tech center and doing labs or bookwork. I liked having an actual connection with the patients while feeling professional. It was hard to be professional with the other students studying at JATC because we are all so close and it is weird to treat a friend
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10 A clinical management plan (CMP) is a triple agreement which has voluntary prescribing partnership between independent prescriber ( a doctor or dentist)‚ a supplementary prescriber and patient (Department of Health 2005). Partnership is a key principle and plan should be drawn up with patient agreement. ( Belton‚ 2014)The independent prescriber is responsible for diagnosis of the patient‚ make decisions with the supplementary prescribe who may review the patient and manage long term care (Lymn
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The purpose of clinical supervision is to help teachers understand their practice better and self-reflect on their instruction. Principals and teacher colleagues serve as clinical supervisors and their job is to help the teacher select goals to be improved‚ teaching issues to be addressed‚ and give feedback to help increase the teacher’s performance. Ultimately‚ clinical supervision is a framework for helping teachers research their practice. There are five general steps to the clinical supervision
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Clinical reasoning Clinical reasoning involves nurses learning and practical experience to play. Any errors or misjudgement can lead to various adverse conditions (Levett-jones et al‚ 2010). Identification of patient problems‚ understanding his situation‚ collecting information and cues followed by processing the information and identifying the key problems‚ establishing goals‚ taking action‚ evaluation of outcomes‚ and reflection is what forms the clinical reasoning cycle. All these areas should
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patient. I believe that having 4 patients allows me to spend enough time with my patients and get all of my cares completed in a timely manner. I think if I had any more than 4 patients‚ I wouldn’t get the chance to get to know my patients like I do
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1SA1a. During my clinical rotation a significant change I noticed in a patient was a decrease in blood pressure while exercising. Prior to exercise my patient had a blood pressure of 115/60mmhg. While running on the treadmill his blood pressure had dropped to 82/55mmhg. I alerted the nurse of his blood pressure immediately after taking the blood pressure. The nurse was aware and said it has been ongoing. We assessed the patient who was lightheaded‚ gave him some water and told him to stop exercise
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he is actually talking about his own life and how he wouldn’t mind it being over. He also shows depression when he says “How stale‚ flat‚ and unprofitable seem to me all the uses of this world”(1.2.138). This shows how Hamlet is now experiencing clinical depression because he has lost his motivation to keep living as well as him not interested in anything. When Hamlet meets the ghost and becomes influenced by it‚ Hamlet can’t tell whether he is doing the right thing or the ghost is
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Based on the situation I encountered during my clinical‚ decision making in clinical settings is a judgment to be made on the patient care and as nurses‚ our judgment on patient care must be professional. We also need to be aware of the possibilities of our actions and decision. Clinical decision making does not only rely on the individual‚ but in a health care setting‚ the decision doesn’t just come because looking at my situation‚ I didn’t ask any other nurses about their opinion but I was just
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Clinical decision making can be defined as‚ the collection of relevant patient information and accurate assessment‚ which results in an action being taken in the delivery of nursing care to the patient (Clark 1996). This definition is identical to the nursing process as described by (ref ewles & simnett?) however‚ this has been disparaged by some for not being critical in its stages (assesment‚ planning‚ implementation and evaluation) leading to standardized care plans and the reduction in decision
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