Academic Clinical Discharge Summary Note

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Academic Clinical Discharge Summary Note

Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, to develop and demonstrate critical thinking and clinical reasoning skills, and to practice identifying acute and chronic problems and formulating a evidence-based plans of care.

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical. The discharge summary note should include the following: ( Acute Care Hospital)

1. Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.

2. List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.

3. Complete list of consults during hospitalization: Include any providers or services consulted during stay.

4. Patient’s condition at discharge: Include a physical exam prior to discharge that documents that patient is stable at discharge and has safe disposition and transportation. What diagnostic criteria confirmed the discharge diagnosis?

5. Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.

6. Pending test results for follow up: Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on final results.

7. Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.

8. Complete list of discharge follow-ups: Full list of any therapies, treatments, referrals, consults, and follow-up appointments. What diagnostic criteria were needed after discharge?

9. Summary: What questions were raised during the hospital stay? Include all explanations and answers to these questions. What questions were raised that required further exploration? What kind of discharge planning did you need? Characterize your patient interaction activities.

10. Overall assessment: Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes.

Incorporate 3-5 peer-reviewed articles in the assessment or plan. (Minimum 1000 words).

Don’t Forget to include all coding including ICD-10, CPT and all others.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Week 5: Endocrine System Disorders and the Treatment of Diabetes

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Pharm

Week 5: Endocrine System Disorders and the Treatment of Diabetes

The endocrine system includes eight major glands throughout the body which affect such things as growth and development, metabolism, sexual function, and mood (National Institutes of Health). Some of the most commonly diagnosed endocrine disorders include hypothyroidism, diabetes, and Hashimoto’s disease. Not surprisingly, treating any one endocrine disorder may have effects on other body systems or their functions. As an advanced practice nurse, treating patients who may suffer from endocrine disorders requires an acute understanding of the structure and function of the endocrine system. Additionally, a solid understanding of patient factors and behaviors will assist in developing the best drug therapy plans possible to treat your patients. Some of most commonly diagnosed endocrine disorders include

This week, you differentiate the types of diabetes and examine the impact of diabetes drugs on patients. You also evaluate alternative drug treatments and patient education strategies for diabetes management.

Discussion: Diabetes and Drug Treatments

Each year, 1.5 million Americans are diagnosed with diabetes (American Diabetes Association, 2019). If left untreated, diabetic patients are at risk for several alterations, including heart disease, stroke, kidney failure, neuropathy, and blindness. There are various methods for treating diabetes, many of which include some form of drug therapy. The type of diabetes as well as the patient’s behavior factors will impact treatment recommendations.

For this Discussion, you compare types of diabetes, including drug treatments for type 1, type 2, gestational, and juvenile diabetes.

Reference: American Diabetes Association. (2019). Statistics about diabetes. Retrieved from http://diabetes.org/diabetes-basics/statistics/

To Prepare

· Review the Resources for this module and reflect on differences between types of diabetes, including type 1, type 2, gestational, and juvenile diabetes.

· Select one type of diabetes to focus on for this Discussion.

· Consider one type of drug used to treat the type of diabetes you selected, including proper preparation and administration of this drug. Then, reflect on dietary considerations related to treatment.

· Think about the short-term and long-term impact of the diabetes you selected on patients, including effects of drug treatments.

 

Post a brief explanation of the differences between the types of diabetes, including type 1, type 2, gestational, and juvenile diabetes. Describe one type of drug used to treat the type of diabetes you selected, including proper preparation and administration of this drug. Be sure to include dietary considerations related to treatment. Then, explain the short-term and long-term impact of this type of diabetes on patients. including effects of drug treatments. Be specific and provide examples.

1. Develop a teaching PowerPoint or poster board to teach presumptive signs of pregnancy to a woman who is planning to get pregnant (Amenorrhea, Nausea, Frequent urination, Quickening, Breast changes, Pigment changes)

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Project must be typed neatly, ideas presented clearly and in sequenced order

List references.

Tips: When putting information together for patient teaching, remember to use language (terminology) that will be easy for the patient to understand the information.

Topics:

1. Develop a teaching PowerPoint or poster board to teach presumptive signs of pregnancy to a woman who is planning to get pregnant (Amenorrhea, Nausea, Frequent urination, Quickening, Breast changes, Pigment changes)

Part 1. The Systems Development Life Cycle for Implementation

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Part 1. The Systems Development Life Cycle for Implementation

In a 2-page narrative, address the following:

  • Explain each step of the systems development life cycle (SDLC) for a nursing informatics project. (1 page)
  • Explain why nurse leaders should be involved in each step of the SDLC by identifying at least two ways that nurse leaders can contribute to best practices for implementation of nursing informatics projects. Be specific and provide examples. (1 page)

Part 2. Job and Role Description of the Nurse in Systems Development and Implementation

Develop a 1- to 2-page job and role description for a graduate level nurse to guide his/her participation on the implementation team for a new nursing documentation system. The job and role description should be based on the systems development life cycle (SDLC) stages and tasks, and should clearly define how this individual will participate in and impact each of the steps.

  • Define the role of the nurse in the planning and defining requirements stage of the SDLC. (1–2 paragraphs)
  • Define the role of the nurse in the analysis stage of the SDLC. (1–2 paragraphs)
  • Define the role of the nurse in the design of the new system stage of the SDLC. (1–2 paragraphs)
  • Define the role of the nurse in the implementation stage of the SDLC. (1–2 paragraphs)
  • Define the role of the nurse in the testing and maintenance stages of the SLDC. (1–2 paragra

Submit      an essay of the developed action plan for a community educational project.

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Overview

You will need to reference Healthy People 2020 (HP2020) when selecting your topic and state the corresponding objective number from the website upon which you are basing your project. For example: If your topic is the prevention of obesity, you may select objective NWS-9: Objective NWS-9

  1. Submit      an essay of the developed action plan for a community educational project.      The project plan should include 2 (two) goals and objectives based on your      topic from Healthy People 2020, an implementation plan for implementing      these activities, a budget (if necessary, not required), a justification      for the project, a description of where and when the plan will be      implemented, and a description of the teaching materials which will be      utilized during the execution of the project. Then recommend nursing      actions/interventions to improve the health concern and achieve your      stated goals and objectives. Discuss potential public and private      partnerships that could be formed to implement your recommendations and      create a timeline (i.e. 3 month, 6 month) for potential expected outcomes.

The assignment should be written in an APA-formatted essay. The essay should be between 1250 and 1500 words in length and include at least two scholarly sources other than provided materials

Describe barriers to the implementation of patient-centered evidence-based care in your practice environment and share actions that might be taken to alleviate these barriers. 

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Discussion Question:

Define patient-centeredness in the context of evidence-based practice. Describe barriers to the implementation of patient-centered evidence-based care in your practice environment and share actions that might be taken to alleviate these barriers.

Your initial posting should be at least 400 words in length and utilize at least one scholarly source other than the textbook

In your Module 2 Assignment, you create a database diagram for the database that you proposed in the Week 3 Discussion and built upon in the Week 4 Discussion

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Blueprints are used by others besides architects. New home buyers may use the blueprint of their future home to better understand the architect’s vision and to consult with the architect on changes. Municipalities will use the blueprint to issue building permits. Builders will use it to plan construction and estimate costs.

Likewise, you don’t have to be a database designer to apply visual tools such as database diagrams. For example, creating or studying a database diagram can help you, as a leader in a healthcare organization, understand the data needs of the organization or of your team.

This is in turn can create efficiencies and drive improvements at varied levels of patient care. As a nurse, database diagrams can help you analyze the data structure and how to make best use of the available data and functionality in the provision of care. At every level of an organization, an understanding of database diagrams can help in providing feedback to database managers that in turn can help drive improvements.

In your Module 2 Assignment, you create a database diagram for the database that you proposed in the Week 3 Discussion and built upon in the Week 4 Discussion. You also create a PICOT question to be used to search your proposed database. Finally, you develop an analysis of your database design, explaining the proposed structure and design elements while justifying your approach.

To prepare:
  • Review the Learning Resources.
  • Review your posts from the Weeks 3 and 4 Discussions and the scenario on which they are based.
  • Consider a clinical research question you might ask that could be informed by the data in your database.
  • Restate your clinical question as a PICOT question.

Assignment (2- to 3-page paper and a diagram of a database as an appendix):

Using the scenario from Week 3, create a diagram of your proposed database using Microsoft Word.

  • Include the additions made in Week 4.
  • Complete the diagram first, but place it as the final page or pages of your submission. The diagram is separate from the required page count.

In the narrative portion of the assignment:

  • Explain how your diagram articulates your planned design.
  • Explain the principles behind selecting key fields and defining relationships. Be specific and support your response with evidence.
  • Write a sample PICOT question (i.e., a query) you might ask based on the information in the database created during Weeks 3 and 4 to demonstrate your understanding of the connection between data and research.
  • List the tables in the database that you would need to include when answering your question.

Your quest to purchase a new car begins with an identification of the factors important to you. As you conduct a search of cars that rate high on those factors, you collect evidence and try to understand the extent of that evidence.

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Your quest to purchase a new car begins with an identification of the factors important to you. As you conduct a search of cars that rate high on those factors, you collect evidence and try to understand the extent of that evidence. A report that suggests a certain make and model of automobile has high mileage is encouraging. But who produced that report? How valid is it? How was the data collected, and what was the sample size?

In this Assignment, you will delve deeper into clinical inquiry by closely examining your PICO(T) question. You also begin to analyze the evidence you have collected.

To Prepare:

  • Review the Resources and identify a clinical issue of interest that can form the basis of a clinical inquiry.
  • Develop a PICO(T) question to address the clinical issue of interest you identified in Module 2 for the Assignment. This PICOT question will remain the same for the entire course.
  • Use the key words from the PICO(T) question you developed and search at least four different databases in the Walden Library. Identify at least four relevant systematic reviews or other filtered high-level evidence, which includes meta-analyses, critically-appraised topics (evidence syntheses), critically-appraised individual articles (article synopses). The evidence will not necessarily address all the elements of your PICO(T) question, so select the most important concepts to search and find the best evidence available.
  • Reflect on the process of creating a PICO(T) question and searching for peer-reviewed research.

The Assignment (Evidence-Based Project)

Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews

Create a 6- to 7-slide PowerPoint presentation in which you do the following:

  • Identify and briefly describe your chosen clinical issue of interest.
  • Describe how you developed a PICO(T) question focused on your chosen clinical issue of interest.
  • Identify the four research databases that you used to conduct your search for the peer-reviewed articles you selected.
  • Provide APA citations of the four relevant peer-reviewed articles at the systematic-reviews level related to your research question. If there are no systematic review level articles or meta-analysis on your topic, then use the highest level of evidence peer reviewed article.
  • Describe the levels of evidence in each of the four peer-reviewed articles you selected, including an explanation of the strengths of using systematic reviews for clinical research.  Be specific and provide examples.

Part 2: Advanced Levels of Clinical Inquiry and Systematic Reviews Create a 6- to 7-slide PowerPoint presentation in which you do the following: · Identify and briefly describe your chosen clinical issue of interest. · Describe how you developed a PICO(T) question focused on your chosen clinical issue of interest. · Identify the four research databases that you used to conduct your search for the peer-reviewed articles you selected. · Provide APA citations of the four peer-reviewed articles you selected. · Describe the levels of evidence in each of the four peer-reviewed articles you selected, including an explanation of the strengths of using systematic reviews for clinical research. Be specific and provide examples.–

Excellent 81 (81%) – 90 (90%)Good 72 (72%) – 80 (80%)Fair 63 (63%) – 71 (71%)Poor 0 (0%) – 62 (62%)

Written Expression and Formatting—Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided, which delineates all required criteria.–

Excellent 5 (5%) – 5 (5%)Good 4 (4%) – 4 (4%)Fair 3.5 (3.5%) – 3.5 (3.5%)Poor 0 (0%) – 3 (3%)

Written Expression and Formatting—English Writing Standards:
Correct grammar, mechanics, and proper punctuation.–

Excellent 5 (5%) – 5 (5%)Good 4 (4%) – 4 (4%)Fair 3.5 (3.5%) – 3.5 (3.5%)Poor 0 (0%) – 3 (3%)Total Points: 100

How would you apply the principles of the Triple Aim initiative to improve quality, safety and satisfaction in the acute care or long-term care setting?  

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Reflect upon the patient experience, patient safety, and healthcare cost as well as Joint Commission’s role in quality healthcare. Write a paper that addresses the following questions:

  • How would you apply the principles of the Triple Aim initiative to improve quality, safety and satisfaction in the acute care or long-term care setting?
  • Reflect on your current or future role in healthcare. How you would you, in the role of director of nursing or healthcare administrator contribute to improving cost effective quality care, patient satisfaction, and patient safety?
  • What practices would you apply to minimize medical errors among front-line nursing staff?

Analyze clients presenting for treatment of anxiety disorders Evaluate effectiveness of therapeutic approaches for clients diagnosed with an anxiety disorder

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Clinical Supervision is an essential component of your development as a psychiatric mental health nurse practitioner. It provides an opportunity for professional collaboration as you share experiences with and gain insights from colleagues. For this Clinical Supervision, consider a client whom you do not think is adequately progressing according to expected clinical outcomes.

Learning Objectives

Students will:
  • Analyze clients presenting for treatment of anxiety disorders
  • Evaluate effectiveness of therapeutic approaches for clients diagnosed with an anxiety disorder

To Prepare:

  • Review this week’s Learning Resources concerning treating patients with anxiety disorders.
  • Reflect on a child or adolescent client you are currently counseling or have previously counseled at your practicum site who has been diagnosed with an anxiety disorder.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click submit, you cannot delete or edit your own posts and cannot post anonymously. Please check your post carefully before clicking Submit!

By Day 3

Post a 3- to 5-minute Kaltura video in which you do the following:

  • Describe the client. Note: Do not use the client’s actual name.
  • Explain your therapeutic approach with the client, including the perceived effectiveness of your approach.
  • Identify any additional information about this client that may potentially impact expected outcomes.