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Comprehensive essay on clinical experience
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Going into my first week of clinical, I did not know what to expect. I was nervous the first couple of weeks due to the fact I am an introverted person and have never experienced anything like clinicals before. As the weeks went on, I became more comfortable and not as intimidated of the clinical setting. Clinicals gave me the opportunity to get out of my comfort zone and learn so many amazing things about healthcare. I was able to see many neat things while in clinicals. One of the neatest things I saw and will never forget, was when I was in respiratory therapy and I was able to see a patient be intubated. I had never realized how many healthcare professionals are involved when intubating a patient. There was around ten healthcare workers …show more content…
Everything has to be documented to ensure the best care for the patient. During my clinical experience I was able to read the charts of a patient in the critical care unit. Since everything was documented about this patient I learned everything about this patient from the time they were admitted to the hospital. There was even documents about the patients before they were admitted to the hospital. Reading the documents about the patient helped me understand what was going on with the parwint without having to ask the RN. Documentation helps you understand everything about a patient. There was a time in clinicals where documentation did not work. When I was in radiology, one of the MRI techs was reading the charts of a patient they were about to scan and the tech could not figure out why the patient needed special care. The patients charts went all the back to 2013 and the tech could not figure out this patient. The tech had to end up calling the RN taking care of this patient to figure out what to do. It turns out that not everything was documented with the patient and there were holes in the chart that needed to be filled. When documentation is done right it makes healthcare professionals lives so much easier. Healthcare workers do not have to try to figure out the holes in a patient's chart. After seeing the MRI tech get frustrated over the patient's chart, I realized how important documentation was in healthcare. I have always heard about the importance of documentation but after clinicals I was able to understand just how important it is. Documentation is everywhere in healthcare and it plays an important role in providing exceptional care for a
This practicum project experience project plan is the initial step in addressing an identified deficiency in the new CPOE/clinical documentation system implemented last year at the medical center at which I am employed. Using the standardized tools of project management, I have presented the project objectives, the global project methodology, and the formative and summative evaluation criteria. To further describe this project plan, a graphical timeline is shown in figure 1. A narrative explanation of the timeline is included in the appendix. Finally, this project plan is supported by scholarly and peer-reviewed literature.
The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare tea...
chartings in the medical record of a patient, taking the patients vitals and reporting abnormal to
... basic information of the patient. Professional and precise language should be used when documenting. For the care plan, I have learned to correctly write a nursing diagnosis and writing interventions that are within nurses’ capability and suits the patient’s personal status. From now on, I will remember to distinguish medical diagnosis from nursing diagnosis. For each diagnosis, I will write about the patient’s (potential) response to the health problem and state why this might be the concern.
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
I followed the RN nurse who was to assist and prep the operating room (OR). She first went into the clean utility room, where she picked up essentials for the surgery. When everything was gathered and prepared, we had to sit and wait for the patient who had arrived late. The RN would check the computer constantly to see if the patient was on file. After the clock hit 9, which was the time for the surgery, the RN nurse decided to go help put the patient on file quicker. When we arrived at the patients room, there was a nurse making the patient fill out papers. The RN nurse took over the papers while the other nurse completed the documents on the computer. While watching all the questions being asked, and the time it took to fill out the paper work, I realized that the paper work process is not easy.
My first clinical experience as a Diagnostic Medical Sonographer student was at North Shore Medical Center. I was very nervous my first day, because I didn't quite know what to expect, and how much I was going to be doing as an intern in this course. Even though we were given all the information by our instructors at school it is a completely different experience to actually be at the hospital and try to help and perform with a team of professionals and their patients. I was assigned a second shift which would last from the afternoon till late evening hours which gave me the opportunity to be exposed to different situations and a variety of cases involving Emergency Room patients and Labor and Delivery patients and some ICU and CCU patients. I had the opportunity to work with different Clinical Instructor professionals who gave me the opportunity to build confidence and gain experience in observing their work during a shift from start to finish.
Clinical documentation improvement (CDI) is the process of reviewing the clinical documents by specialists to response to concerns regarding coding issues, quality and care management of patients’ services. According to Oach and Watter, hospitals invest in CDI programs to guarantee the contents of electronic health records (EHR) indicate actual conditions of their patients. CDI assists in reducing chances of unclear and incomplete documents, which may lead to losing hospitals’ revenues. CDI promotes the accuracy of documentations, which results in correctly coded and billed to insurances to decrease rejection rates, increase payments compliance, and improve quality of report for researches of public health data and diseases’ trends. CDI is
This information requires to be particular, reliable, and offer a perspective that simplifies action that directs to approaches that enhance care delivery, effectiveness, expenditures, and eventually outcomes. Healthcare organizations progressively require to measure their performance, from effective and quality assessments, in addition to from the evaluations of the populaces they work for, and to persistently develop and achieve their planned aims. For healthcare workers, high- significance, actionable information enhances the art and science of care delivery by confirming that they have get into to the top, most up-to-date, and most appropriate clinical information at the point of patient communication. For payers and insurers, actionable information can link all the participants in a technique that would be almost unachievable without a substantial speculation in other resources. Performing a significant role in providing the subject, guidelines, and increasingly programmed and intelligent clarifications, payers can remain to change their responsibility from processors of claims to enablers of superior, perfect, reliable, and evident care, all while eliminating the organizational incompetence that occur in providing and in paying for applicable
My first week of clinical definitely had its strengths and weaknesses. For weakness, I felt overwhelmed both days because I have not yet developed a routine in regards to assessments, care plans, and developing an order for medication administration. I also had difficulty understanding certain orders from providers. However, my nurse was very helpful in explaining every situation and reassuring me that it takes time to develop a system. One thing I did to understand orders better was to write down what the order meant, so when I had another patient I could look up what the steps were to collect the specimen.
Clinical placements allow student nurses to put theory into practice with real patients and actual clinical situations. Every placement will challenge student, improve communication skills, build own knowledge and foster own reflective practice. It is one of the most interesting and exciting aspects of training to be a nurse. I personally believe that, students must be responsible for their own learning opportunities and understand the outcomes they need to achieve on placement, discussing any queries with their clinical supervisor. I always look for learning opportunities. I approach my clinical supervisor for her guidance to perform any new skills fall into my scope of practice.
I believe placing student nurses in the clinical setting is vital in becoming competent nurses. Every experience the student experiences during their placement has an educative nature therefore, it is important for the students to take some time to reflect on these experiences. A specific situation that stood out to me from my clinical experience was that; I didn’t realize I had ignored the patient’s pain until I was later asked by the nurse if the patient was in any pain.
Every facility has desires they stick to, yet require legitimate documentation of well-kept records to be used to treat and to analyze the patient. There are various types of health care setting for examples: Acute Care Hospitals, Mental Health Clinics, Substance Abuse Hospital and Rehabilitation Facilities. In an Acute Care hospital, the patient is
Starting a clinical on a new unit was very nerve-wracking. Being a third year nursing student, there are
Documentation is a form of communication that provides information about the patient and confirms that care was provided to that patient. Some reasons why nurses document is for communication and continuity of care of the patient and by that it means clear, complete and accurate documentation in a health record ensures that all those involved in a client’s care, including the client, have access to information upon which to plan and evaluate their interventions. Next, quality improvement/assurance and risk management through chart audits and performance reviews documentation is used to evaluate quality of services and appropriateness of care. Additional reason is it establishes professional accountability because documenting that is showing a valuable method of demonstrating that nursing knowledge, judgment and skills have been applied within a nurse-client relationship in accordance with the Standards of Practice for Registered Nurses. Another purpose is for legal reasons the client’s record is a legal document and can be used as evidence in a court of law or in a professional conduct proceeding. Courts may use the health record to reconstruct events, establish time and dates, and refresh one’s memory and to substantiate and/or resolve conflicts in testimony. Although you may never be named as a defendant in legal case, you may be called to testify at a discovery or