May 30, | nursing, med, NURS, Paper
iHuman Documentation Guide
iHuman Documentation Guide
Use this guide to help you complete documentation within the iHuman Virtual Patient Encounter. All documentation for the patient visit must be entered into the iHuman platform.
EMR Documentation
Use the Patient Record to document pertinent information related to your history and physical exam. You are able to access and update the patient record any time while you are playing your assignment by clicking on the Show Patient Record button. Click the iHuman Documentation Guide Hide Patient Record button to return to your patient.
Include pertinent information for the focused assessment using the tabs within the EMR:
EMR tips
Chief complaint (CC) is a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”. Sometimes a patient has more than one complaint. For example, if the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom
Use OLD CARTS to document history of present illness (HPI)
Be sure to include all past medical history, medications, and allergies.
Include reaction/response to each allergen.
Include dosage, frequency, length of time used and reason for use for each medication; also include OTC or homeopathic products.
Limit preventive health, family, and social history to findings pertinent to the HPI.
Social history may include but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as seat belt use all the time or functional smoke detectors in the house, etc.
Family history may include but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included, for example, parents, grandparents, siblings, and children. Include grandchildren if pertinent.
In your review of systems (ROS), address all body systems that may help rule in or out a differential diagnosis. Limit ROS documentation to positive and negative findings pertinent to focused health history. Describe findings; do not use WNL.
Information gathered during the physical examination by inspection, palpation, auscultation, and percussion should be documented under physical exam. Limit physical exam documentation to findings pertinent to your focused assessment based on the chief complaint. If unable to assess a pertinent body system, write “Unable to assess”. Document pertinent positive and negative assessment findings iHuman Documentation Guide. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed. Describe findings; do not use WNL.
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Key Findings
Add key findings at any time during your history or physical exam by clicking the + sign. Key findings may be organized using the up and down arrows. You will organize the key findings further in the Assessment step.
Problem Statement
Problem Statement: Document a problem statement using professional language. You will include pertinent demographic data, a brief description of the HPI and other pertinent subjective findings, and a brief description of pertinent objective findings. Use the data that you collected and documented in your EMR and summarize the data in the problem statement. Note that the problem statement has a 155-word limit. iHuman Documentation Guide A sample problem statement is shown below.
Management Plan
Using the expert diagnosis provided, create a comprehensive treatment plan using professional language. Use headings to address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but be sure to address each area. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention. Include at least one appropriate, evidence-based, scholarly source to support your decisions. A sample management plan is shown below.
Management Plan Tips:
Diagnostic tests: Appropriate tests have been provided within the iHuman case. Include the tests ordered in your management plan. Do not include results. You need not provide rationale or citation for diagnostic tests.
Medications/treatments: List medications/treatments including OTC drugs you will order and “continue meds” if pertinent. Include appropriate, evidence-based treatment recommendations. Explain the rationale for your decisions and provide support from scholarly literature with an in-text citation.
Consults/referrals: Provide a list of appropriate referrals. Include a rationale for each and provide support from scholarly literature with an in-text citation.
Client education: Provide documentation of appropriate client education. Include a rationale and provide support from scholarly literature with an in-text citation.
Follow-up: Indicate when patient should return and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere.
Be sure to include the full reference for all in-text citations used. You will not be able to use italics for the title of your journal article within iHuman documentation.
You need only 1-2 EBP references for the SOAP note. Each reference must support your selection of interventions and guide clinical decision making. The best references are national guidelines or treatment protocols.
You may choose to complete the SOAP note within a Word document and copy/paste to the iHuman Plan tab when complete iHuman Documentation Guide.
May 30, | nursing, med, NURS, Paper
My personal nursing philosophy essays
My personal nursing philosophy essay
My Personal Philosophy
My philosophy about the nursing profession is that I view it as a calling, a privilege indeed, to be in a position where I can use my knowledge and skills driven by my compassionate and caring nature to provide holistic care to my patients. The course is to treat them with respect, honesty, and dignity without any bias or discrimination to enhance wellness.My personal nursing philosophy essays:
I clearly remember asking my mother one day what I would be when I grew up My personal nursing philosophy essay. She told me I would be a good nurse and that I should consider it as a profession. After that conversation, I never gave any other profession a thought.
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I feel that my philosophy revolves around an empathetic, compassionate and patient-centered care. As nurses, we are in a position to influence the individual, a community and the larger society as change agents in promoting healthy lifestyles and shaping policies that affect social determinants which are critical in health care. Holistic care does involve taking care of a patient’s spirit, mind, body, emotion, and environmental well-being and that is way out of the great nursing theories that I have learned I tend to associate my practice with the works of the nightingale (Pitt et al., 2014) My personal nursing philosophy essay.
Florence Nightingale developed the environmental theory in which she did give a detailed explanation of 13 fundamental canons of the environment that she believed if nurses would make an effort to modify the patient’s environment according to her rules they would be significant in quick recovery of the patient (Medeiros, Enders & Lira, 2015). Her 13 rules include cleanliness of rooms and walls, ventilation, noise, light, personal sanitation, bed and bedding, and proper diet. Taking care of these factors is an excellent step towards holistic care. At the clinical level, positive outcomes on patients can be facilitated by attaching an environmental checklist besides the patient’s bed which will compel nurses to act on such factors. At the community level, Nightingale’s concept of environment can be facilitated through awareness and campaigns through various media on the importance of environmental hygiene and the impact on health. I firmly believe if the ecological theory is applied into the familiar and clinical concept most of the disease, infections and spread of communicable diseases can be toned down by a significant margin and health is promoted of which are among the roles nurse play (Medeiros, Enders & Lira, 2015). As an infection preventionist, I support Nightingale’s statement that the specific scientific activity of nursing is hygiene, and the central element in health care, without which medicine and surgery would be ineffective (Smith & Parker, 2015).
I believe that I got some basic qualities that are relevant to my nursing careers, like good communication and interpersonal skills, flexibility, critical thinking and problem-solving skills, empathetic compassion, and emotional stability (Pitt et al., 2014). My kind nature led me to pursue nursing which I had thought would be a smooth ride in gaining the knowledge, skills, and experience, but what I have learned is that it is not for the faint-hearted, as some scenes, occurrences, and cases can leave one stressed out or even traumatized. Thanks to a supportive family, my colleagues, tutors, and mentors I seem to have overcome that barrier and grown emotionally. I perceive nursing as a noble career that surpasses the need for that monthly check as it purposely deals with an aspect that can neither be quantified nor assigned a monetary value, health, and well-being. In my personal nursing philosophy essay I understand the role of nurses as advocates, to actualize the environmental theory I opt to put it into practice when dealing with my patients and counsel, educate and empower them to practice healthy living and self-care. I believe one can change society by dealing with individuals.
I can describe a patient as one that is in need of medical care to enhance their well-being and while on the process their environment plays a critical role. Beginning with the nurses, I believe in the mirror technique that is we cannot advocate for better care of others without modelling positive behaviour in our lives as role models (Hoeve, Jansen & Roodbol, 2014). Self-care is, and I abide by it through proper diets, exercising, having adequate sleep and rest, and minimizing risks within my environment that pose a danger to my health. Nursing as a practice is changing fast. Thanks to continued research and advancement the current world seems to spin fast with significant developments in health care and evidence-based practices. My personal nursing philosophy essay That is why I commit to enrolling in continuous learning to keep tabs on the current and evolve seamlessly throughout my career. I am open to any teaching be it from my personal experience in healthcare or interaction with colleagues, patients, and their families.
My strengths and core values act as a guide towards achieving a lifelong career in nursing to impact as many lives as possible through patient safety, healing, and empowerment. My motivating factor is that each day comes with new opportunities and I am better than I was yesterday and will continue to stride with confidence upholding my personal and professional ethical standards always. My nursing experiences had changed my worldview of nursing practice as before I had only perceived it narrowly as a career that only deals with the treatment and patient care but coming to learn of it, it is a practice with a widened scope capable of changing the society via influencing the primary social determinants. My current vision is to bring change and hope to my patients, change their perspective of life and be an inspiration to my juniors that would like to join the nursing profession shortly (Hoeve, Jansen & Roodbol, 2014) My personal nursing philosophy essay.
References
Smith, M. C. & Parker, M.E. (2015) Nursing theories & nursing practice (4th Ed.). Philadelphia,
PA: F.A. Davis
Hoeve, Y. T., Jansen, G., & Roodbol, P. (2014). The nursing profession: public image, self‐concept and professional identity. A discussion paper. Journal of Advanced Nursing, 70(2), 295-309.
Medeiros, A. B. D. A., Enders, B. C., & Lira, A. L. B. D. C. (2015). Florence Nightingale’s environmental theory: A critical analysis. Escola Anna Nery, 19(3), 518-524.
Pitt, V., Powis, D., Levett-Jones, T., & Hunter, S. (2014). The influence of personal qualities on performance and progression in a pre-registration nursing program. Nurse education today, 34(5), 866-871 My personal nursing philosophy essay.
