Tuesday, March 29th, 2016: Montana State Hospital The day began with a care conference by an interdisciplinary team (psychologists, social worker, nurses, and psych techs). Every patient on the wing was discussed about their current situation, behavioral problems, or change in care plan. The nursing process seemed to be utilized when dealing with these problems. The problem was assessed by the entire team, the root cause was determined, a plan was established to implement, and then would be evaluated the next day. Following the care conference, we observed an intake of a new patient.
I rounded daily with every department (ICU, MSU, PNU, L&D, BHU) and met every patient. I would receive report from each department Charge Nurse and CNS (who was also novice). I spot checked documentation in the Essentris computerized charting and randomly would check on drug administration. I was involved with disease and discharge management and followed up on all referral consults and processes. I would meet with every CNS quarterly and work on their clinical challenges and also what Process Improvement Projects they were currently working on.
Today our clinical group participated in the hospital’s wound prevalence day where we helped the wound nurse do head to toe skin assessment to the patients who are not/at risk for developing pressure ulcer and do HillRom/CALNOC study checking the quality of the bed mattresses. In the early morning, we spent our day first thing by reviewing as many charts as possible and filling out the forms needed for the study. Nurse Brittany, the wound nurse, assigned the participants into teams which included one nurse with at least two students to various units. My two other classmates and I were assigned with Samantha, RN to do the prevalence study at Med-Surge and ICU unit. Some of the tasks we did as a group comprised of: assessing the patient; checking the mattress’s condition; counting how many layers of linen the patient uses; checking heels if they are offloaded; noting if patient has secure foley catheter; marking the mattress “G17” for good and “B17” for bad; educating the patient and family on prevention
As always, the very first step of Nursing care begins when we enter the patient’s room for assessment. The way we introduce ourselves or talk to patients the first time determines the way the entire relationship will unfold. That speaks volumes when it comes to Nurse-patient relationship. Nurse assesses patient’s and his or her own understanding of what is happening Gorman (2008). I do realize that the more we interact with patients, keep our differences or problems behind us, the more the patient becomes more open to discussion about patients’ needs and wants.
Outcome: she led a subcommittee of the hospital Restraint Committee to get the restraint product approved. Twice as Tough Cuff She also developed a training process so that every nursing staff can be trained and ready to go live by the end of September of this year. 70% of staff has already been trained. She presented and taught on the Twice as Tough Cuff restraint during the August 20th hospital-wide Skills Fair. Last, she reviewed and updated the current hospital restraint education power point located on VHATAM
The information is automatically gathered by the ICU information system; nurses have the option of either accepting or modifying the data. In typical clinical settings, nurses perform the selection and transfer of bedside monitoring data from the ICU information system to the EHR about once an hour. These ICU information systems typically retain the high frequency bedside monitoring data and can achieve near-real-time computerized decision support. In many cases, the nurse’s notes are also entered into the ICU information system-generally once per shift-and some summary vital sign information may find its way into those notes. Physician progress notes are also entered into ICU information systems in a similar fashion.
Most healthcare facilities integrate hourly rounding to help reduce falls. A quasi- experimental study was conducted by (Olrich, Kalman, & Nigolian, 2012) to determine the efficiency of hourly rounding in hospitalized patients on a medical-surgical unit. The researchers compromised of nurse managers and a clinical nurse specialist educated the nurses and nursing assistants on the importance of hourly rounding and questions to ask when performing hourly round. Some of the questions asked during the rounds included toileting assistance, pain, position and making sure personal items were within reach. At the completion of the study, there was a 23% decrease in falls and an increase in patient satisfaction on the
An initial assessment will be completed within 24 hours by our multi-disciplinary team comprised of psychiatrists, nurses, and licensed therapists. Patients meet daily with mental health and medical partners and individualized treatment plans are created. In addition to psychiatric care, we provide individual therapy, family therapy, recreation therapy, group therapy, discharge planning, and medication management. Our educational department provides on-site school support. Please contact our Admission Department for questions regarding transportation, insurance information or to schedule a no-cost
Once again, I will describe what a day in the life of a medical coder in long term care may Look like. Similar to the Health Educator, the medical coder usually attends a daily clinical meeting to Discuss the previous day’s events and the plan for the day ahead. Medical coders work closely with MDS or minimum data set nurses as they are responsible for the assessments that are completed For the health care center to get reimbursed for the services provided. They also work closely with Medical billing office employees to ensure that the codes on the UB are correct and match the Coding of the MDS. They would also review the admitting diagnoses of recent admissions into The facility and use the discharge summary to put their diagnosis into the system and discerning The admitting diagnosis and prioritizing them in order or importance for payment