Then, I can be able to evaluate outcomes. During my assessment of Sara Lin, I was able to find out that she was experiencing a pain level of 6 and was having a hard time breathing. If I had not asked her and assessed her pain, I would not have found out that she was having a hard time breathing and that I needed to educate her about using an incentive spirometer to help ease her breathing, which I actually forgot to do during my first attempt at this scenario. During this scenario, I also learned how important patient education is to help my patient understand her situation and how she should properly care for her condition. For instance, I had forgotten during my first attempt to educate Sara about proper wound care. I realized how important it is to incorporate all aspects of her situation, not just how she is feeling pain and has a hard time hearing, but also to focus on her wound. If I had not educated her about wound care, then she would not know how to properly care for her wound, and this might lead to a risk of infection or bleeding and slow time
While participating in the “Deteriorating Patient” simulation, learning to complete a Situation, Background, Assessment, and Recommendation (SBAR) report while caring for a deteriorating patient was the most challenging task to complete. After receiving report and beginning the initial interaction with the patient, my confidence level was on a steady rise. Everything seemed to flow well and initiating conversation while building a rapport with the patient was also very easy to complete. Once the patient started to deteriorate, I found myself becoming unorganized and my thoughts were racing. Though I was managing the situation very well, I called for a charge nurse because I realized I needed help. After calling for the Charge Nurse and asking for assistance, my racing thoughts slowed down some. I used this moment to notify the provider of the patient’s status and request a visit to the patient’s room. Completing the SBAR with a provider in a moment where the situation was hectic is not something I do very well. My
During my clinical day three, I demonstrated entry-level competence in professional nursing practice in caring for patients with multiple and/or complex unmet human needs. I addressed safety needs, safety in medication administration, effective communication, and surveillance for my patients. First, I addressed safety needs my ensuring the appropriate safety measures were implemented for the patients. Some of the safety measures included, wearing non-skid socks, wearing a yellow armband which indicated fall risk, keeping the bed in lowest position, two side rails up, bed locked, and the call light within reach.
Demonstrate effective use of technology to navigate the electronic health record, communicate with inter/intraprofessional teams, and be involved with decision making in the delivery of quality and safe patient care. (Ivy Tech Community College, 2016).
As a consequence of the boost in communication, significantly less misdiagnoses are experienced. Thus, both the patient and medical facility benefit from the reduction in unnecessary readmissions. This undoubtedly places value on the importance of giving the correct initial treatment to patients through the act of successful interprofessional care.(7)
Though the ICD-9 has become outdated, it does not essentially mean that it needs replacement. The structure of ICD-9 consisted of 5 numeric placeholders, which means, there could be over 100,000 possible codes. The expansion of ICD-9 could have been done by increasing the number
The challenges that I am facing are learning how to report the first diagnosis and everything else that follows when coding. Some of the information is not worded in the the text you somehow just have to know by the information that is given. Since this information is new to me, the only thing I can think of that will help me to overcome this challenge is to practice and read the information carefully even if I have to read it 2 or more times to myself to make sure I am reading it correctly. More importantly asking Ms. Pavey when I don 't understand something.
NCCI code pairs must match on member, provider, and date of service. CMS maintains tables of code pair edits and updates these tables on a quarterly
level 2 is used to identify the products, supplies, and services that are not in CPT codes
Federal agencies and private businesses developed conversion tools to aid in the transition (crosswalks and mapping). There are also a few specific guidelines to follow when coding for ICD-10 such as in the selection for the full code. The coder needs to first check the tabular list to know whether or not a 7th character is required. If a dash is included then additional characters is required there is a dash at the end of an alphabetic index entry. If there is not a dash it is still important to be sure by checking the tabular list. ICD-10 diagnoses codes can have three, four, five, six, or even seven characters versus the five in ICD-9. Some of the new features found in ICD-10 are:
How many times have your ICD-10 leadership team asked themselves the question, are we ready for the conversion? The clock is ticking and there’s very little time left for the healthcare organizations that are behind schedule. On October 1, 2015 the healthcare industry will begin to use, process, and exchange ICD-10. Providers and practices should be preparing themselves for the transition and approaching the implementation with confidence.
The patient is a 53 year old male who presented to the ED via EMS intoxicated and reporting suicidal thoughts. The patient denies homicidal ideations and symptoms of psychosis. The patient endorses depressive symptoms including: tearfulness, isolation, and insomnia.
HCPCS codes facilitate the procedure of processing health insurance claims made by insurers such as Medicaid. The HCPCS is divided into two levels or classes. The task of classification lies with the Centres of Medicaid and Medicare Services (CMS) in association with the HCPCS work group and other third party payers. Classification is done quarterly, marking a significant step-up from its previous system of annual updates. Since 2014, the CMS has been implementing several changes regarding the continuation of HCSPCS level II. In this regard, it has facilitated a method by which the public can provide input through a website and comment mechanism. Examples of the HCPCS codes include A1 and KT.
Patient is our teacher. Patch Adams understands himself better after helping Rudy. There is always something to learn from each patient. Some patients with chronic disease know more about it than any practitioner because they live with the disease for decades. Each patient represents a specific case who has different background, personality, preference and conditions. Thus, it is important for practitioner to learn from each patient and document it for future reference.
Investing my time in the care of my patient gives the opportunity to not only assist them in a difficult situation, but also to learn more about their diagnosis and the treatment, while comparing it to what we have learned in class. For example, I had a patient that suffered from Sickle Cell Disease and came to the ER during a crisis. Correlating this case to the books and the content learned in class, these patients receive at least 1000 mL of fluids, pain medication, and oxygen. Additionally, I had a patient with meningitis. This individual presented with common symptoms such as nuchal rigidity, muscle pain, fever, and chills. The doctor performed a lumbar puncture exam and the cerebrospinal fluid was in the cloudy range of the spectrum. According to the medical staff present at the time, this fluid is supposed to be much clear than what it was at the time of the test. Asking questions to my preceptor is another action I take in order to achieve my goals and problem-solve my obstacles. Additionally, I assist in different cases throughout the ER. For example, when a new patients come or when patients are deteriorating, the available nurses go into the room and help the other nurse. In these situations, I go and help as well and gain experience on the procedure to follow in