Tracy Hill MSN Portfolio



Washburn UniversitySchool of NursingNU 608 Health Care Practicum III- Specialty (Family) Clinical Performance Tool(Completed by Student and Faculty)Student__Tracy Hill____________________Semester___Fall 2012______Agency_HealthCare Access and Pediatric & Adolescent Medicine, P.A. Instructor__Bobbe Mansfield_______Clinical performance is based on Universal Outcomes, End of Program Outcomes and National Organization of Nurse Practitioner Faculty Core Competencies of Nurse Practitioner Practice (2011). Nurse Practitioners must demonstrate care that is effective, patient-centered, efficient, timely, and equitable for the treatment of health problems and promotion of wellness. Universal Outcomes: Evaluating BehaviorUniversal Outcomes must be met in order to pass the course. Failure to meet any of the three Universal Outcomes will result in a grade of F. If an F is earned, the Core Competencies will not be consideredUniversal OutcomesDemonstrates honesty and integrity by submitting original work MetNot meton assignments and accepting responsibility for own actions taken/omittedPrioritizes patient safety as the primary consideration in all careMetNot metMaintains professional boundaries with patients, family and Met Not metstaff. Maintains confidentiality at all timesNurse Practitioner Core CompetenciesStudents must achieve an 80% on the final clinical evaluation tool to be successful in the course. These outcomes are only evaluated if the three Universal Outcomes are met. Students who do not meet the competencies within the required practicum hours may be required to successfully complete additional hours before a final grade will be awarded. Points are assigned as follows: Please rate your own performance using the descriptors listed below:0 = no opportunity to experience1 = defined as not meeting expectations; failing to initiate learning experiences; arriving late and unprepared; failure to effectively communicate with the patient, family, preceptor, staff and faculty2 = defined as inconsistently meeting expectations; requires much faculty/preceptor guidance in learning experience/support3 = defined as routinely meeting expectations yet requires more faculty/preceptor direction in learning experiences4 = defined as routinely meeting expectations with minimal support from faculty/preceptor5 = defined as consistently meeting expectations with little guidance; proficient; can perform independently; initiates learning experiences; is well prepared for learning petency NarrativeThe overall goal of the Clinical Performance Tool (CPT) is to assess the student’s progress throughout the practicum using a narrative description of each competency. To provide a description of the total progress, the student is expected to maintain a cumulative narrative of their performance. With each competency and each submission, the student is expected to assign themselves a score from 0-5 (It is not expected that a student will have many scores of 4 or 5 with the first submission). Within the narrative, students are expected to briefly address the following 4 items:. What does this competency mean? What challenges/strengths related to mastery of this competency are present at this point in time?Give 2-3 examples from this practicum experience that best illustrate how you are preforming the selected competency and which support the score you assigned yourself?What do I need to gain additional skills to master this competency?What references/clinical guidelines/point of care tools (if appropriate) have been helpful in achieving this competency?GradingThe Clinical Performance Tool is completed and submitted by the student at the completion of 80 clinical hours, 160 clinical hours, and 225 for a total of three submissions. The first submission must address items 1-13. The second and final submission must address items 1-28. The final submission is graded.NONPF competencies addressed in this course include Independent Practice, Leadership, Quality, Technology/Information Literacy, and Ethics. Competencies are founded on an understanding of pathophysiology, patient presentation, differential diagnosis, patient management, surgical principles, health promotion, and disease prevention. Utilization of communication strategies, principles of quality care, information technology/literacy and ethical principles are expected. NP students are expected to demonstrate an investigatory and analytic thinking approach to clinical situations, professional behavior, effective communication, and a sensitivity and responsiveness to patient culture, age, gender, sexual orientation and ability.NP students are expected to:Red and * represents first submission reflections at 80 clinical hours (9/21/2012)Purple and * represents second submission reflections at 160 clinical hours (10/24/12)Green and * represents third and final submission reflections at 225 hours (11/26/12) 0 1 2 3 4 51.Develop individualized health promotion, disease □ □ □ □x X Xprevention and health protection services for patientsacross the life spanI assess each patient to determine specific needs regarding health promotion, disease prevention, and health protection services. For example, every day at home, at work and in my clinical settings, I promote hand-washing as one of the best ways to prevent illness. I promote this by demonstration and encouraging those who are healthy or ill and their families to cover their cough with their arm and to wash hands to prevent the spread of illness. Additionally, I regularly have the opportunity to educate patients with UTI’s on ways to prevent UTI’s in the future, including: wiping front to back, good hand-washing, urinating before and after intercourse (when age appropriate), drinking plenty of fluids, and urinating often to prevent urinary stasis. I have seen at least10 patients with dx of UTI (ICD 9- 599.0) and regardless of age, I give them the same educational information on ways to prevent UTI’s. This education occurs naturally regardless of the setting, and is true for all patients across the lifespan. I believe I have demonstrated this outcome effectively and will continue to do so. Another example includes discussing with patients current recommendations of colonoscopies every 10 years starting at age 50. In addition, I continue to assess patients to determine age specific evidence based screenings that are needed, including mammograms. According to the American Cancer Society (ACS, 2012), yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health, a clinical breast exam (CBE) should be done about every 3 years for women in their 20s and 30s and every year for women 40 and over. Also, women should know how their breasts normally look and feel and report any breast change promptly to their health care provider. Breast self-exam (BSE) is also discussed for women starting in their 20s. This educational information is shared with each patient, as appropriate. The pediatric office also has a weight management clinic. At risk pediatric patients are screened using BMI and other risk factors as indicators. They see the NP or MD and a nutritionist regularly, and child psychiatrist as well, if needed. We monitor not only their BMI, but their lipids and nutrition and activity levels and meet with them regularly. I recently had an 8 y.o. male pt with a BMI that was off the chart for his age and weight. It’s often tough to talk with kids in this age range and their parents about eating habits and exercise without discouraging the patient. Our first step was to obtain labs and set up a meeting with the onsite nutritionist and hope that the patient keeps his appointments. I feel fairly well versed in evidence based screenings without having to rely heavily on reference materials, although in the pediatric setting, there are so many developmental changes to assess for at each well-child visit that it is difficult to remember everything. The computerized documentation systems used today in many settings allows for reminders of what to ask and when. For example, I saw a patient for their 1 year old check-up; many developmental questions were prompted during the initial check in time with the nurse because the EMAR template asks age-specific questions/details. My job is to verify those answers and do the PE. Templates provided via EMARs are great additions to the PE! Both the pediatric office and HealthCare Access utilize EMAR, and although they are different systems, they are each useful and support the PE well. This time of year both clinics are pushing influenza vaccines. Every patient is asked to get a flu vaccine when they come in to HCA, regardless of the reason for their visit. At the peds office, there are daily flu vaccine clinics, where a patient/parent can call and sign up for a time to come in, and those patients who present for other appointments are asked if they would like the vaccine while they are there. I have seen good promotion of the vaccine at my clinical sites. I plan to continue to promote vaccines, contraception management and other screenings when appropriate. I also try to mention key points such as smoking cessation when appropriate. I plan to continue to expand my knowledge of health promotion and disease prevention and health protection services for patients across the life span. This will likely develop further by seeing increasingly complex patients and being challenged to expand my skills. 10/24/12- Since my last submission I have continued to provide age appropriate health promotion, disease prevention, and health protection services based upon needs that are identified on an individualized basis with each visit. Such needs are identified by presenting patient risk factors, age, gender, history, and life style. The strengths related to mastery of this competency present at this point in time include the diversity of the population served at current clinical sites, including taking care of individuals across the lifespan with working in the pediatric office to working with individuals until age 65 at HealthCare Access, when patients become eligible for Medicare. In the pediatric setting, this includes individuals from birth to age 26, with all forms of insurance, including state health plans and Medicaid. At HealthCare Access, this includes patients without insurance coverage. Patients of all ages are seen with multiple risk factors, including family history of health problems, to having difficulty with financial, social, economic and cultural risk factors. The challenge in these populations is not seeing individuals over age 65. Other than those individuals over age 65, this clinical rotation has allowed me opportunities to master this competency. I continue to improve in this area on a daily basis. I continue to promote disease prevention by proper hand washing each time I enter the patient’s room and before I leave. According the CDC website (2012), “Keeping hands clean through improved hand hygiene is one of the most important steps we can take to avoid getting sick and spreading germs to others.” One way to encourage patients to have good and frequent hand washing is by properly demonstrating good hand hygiene, which I do regularly and will continue to do throughout my career. Patients who see their providers wash their hands, either with approved hand sanitizers, or a soap and water technique, are more likely to wash their hands as well to prevent the spread of germs. Continuing to promote the influenza vaccination remains important during this clinical rotation. These late fall months are the most common months for patients to receive influenza vaccines. According to the CDC website (2012), a yearly flu vaccine is recommended as the first and most important step in protecting against flu viruses and while there are many different flu viruses, the flu vaccine protects against the three viruses that research suggests will be most common. I continue to promote the influenza vaccine to my all my patients over 6 months of age, when appropriate, and will continue this practice as I continue my career. At HealthCare Access, we encourage all patients to obtain an influenza vaccine and provide vouchers to each patient so they may receive their vaccine at no cost at the Douglas County Health Department. At the pediatrics office, we continue to offer flu vaccine clinic times on a daily basis, and if a patient is seen in the clinic for another reason (i.e. “sick clinic”, or “well-child exam”), if they do not have a fever, then we offer them the vaccine at that time. We also offer the vaccine to other pediatric family members who may be present at the time of that visit as well. Basically, we do not turn away patients who want a flu vaccine – we also offer the flu vaccine in a flumist form as well, for those patients who meet the requirements of receiving the flumist. I also continue to ensure pediatric patients are up to date on their immunizations. I also attempt to encourage patients be up to date on their Tdap booster. According to the CDC website, “As of October 18, 2012, more than 32,000 cases (of pertussis) have been reported across the US, including 16 deaths. The majority of deaths continue to occur among infants younger than 3 months of age.”(CDC, 2012). As of September 20, 2012, Kansas, at 17.2/100,000 persons, is among the states with incidence of pertussis the same or higher than the national incidence, which is 9.3/100,000 persons (CDC, 2012). I continue to discuss with patients current recommendations of colonoscopies every 10 years starting at age 50, and yearly mammograms starting at age 40 and continuing for as long as a woman is in good health, and a CBE every 3 years for women in their 20s and 30s and every year for women 40 and over.Patients who present to HCA with HTN, whether they are at their initial or a follow-up visit, are common. According to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), HTN diagnosis is based on the average of two or more properly measured, seated BP readings on each of two or more office visits (nhlbi.). I continue to educate new and established patients on facts about HTN, including that, according to the AHA website (2012) “most of the time there are no symptoms, but when high blood pressure goes untreated, it damages arteries and vital organs throughout the body. That's why high blood pressure is often called the "silent killer." I plan to continue to promote vaccines, contraception management and other screenings when appropriate. I plan to continue to expand my knowledge of health promotion and disease prevention and health protection services for patients across the life span. I will continue to seek opportunities to see increasingly complex patients that will challenge me and expand my skills.11/26/12- Since my last submission, as previously stated, I have continued to provide age appropriate health promotion, disease prevention, and health protection services based upon needs that are identified on an individualized basis with each visit. Such needs are identified by presenting patient risk factors, age, gender, history, and life style. Other than those individuals over age 65, I continue to feel that this clinical rotation has allowed me opportunities to master this competency. I have been flexible and creative in developing individualized services, and have followed sound recommendations with the goals of protecting and promoting health and preventing disease. My preceptor has given me progressively more independence in this process, as I have gained confidence, gotten to know patients, and have progressed through this final clinical experience. I continue to counsel patients who present for WWE on the importance of mammograms when age and risk factor appropriate, and something I’ve done more of is promote immunological fecal occult blood test (iFOBT) screening for colorectal cancer in patients over 50. This is a screening that I feel many patients are unaware of so it was a good educational opportunity. I also had a patient whom I educated on the influenza vaccine. All patients at HCA are asked about receiving the influenza vaccine, and if they are interested, we give them a voucher so they can get it free of charge at the Douglas County health department. I had a gentleman who had stated that he didn’t want to get the flu vaccine because “we have all already had that this year”, meaning “the flu”. I was pretty sure they didn’t have “influenza” based on the timing, and it turned out his family members had probably had gastroenteritis. I educated the patient on “influenza”, and he ended up getting the flu vaccine that day! Another life saved!Since my last submission I have had many opportunities to practice more independently and feel I am ready to practice my skills in a family practice setting. As always, additional opportunities increase confidence and continued development of skills. I plan to stay abreast of current recommendations for health promotion/protection services and disease prevention strategies as defined by reputable sources such as AHRQ, CDC, ACS, and ACOG, as mentioned above. Others include National Center for Chronic Disease Prevention and Health Promotion, KanQuit, Ferri's Clinical Advisor 2012 and more.2. Develop individualized anticipatory guidance and □ □ □ □ X X health counseling for patients across the life span Each patient at HCA is given a wellness questionnaire on arrival and it is reviewed with the patient at that visit. HCA is fortunate enough to have a counselor on staff to meet with patients almost immediately as they need or desire it. This questionnaire also prompts discussions about exercise, health, wellness and depression. Clients are also able to meet with a wellness counselor quickly as well, who is also on staff at HCA. It’s crucial in this setting to anticipate what the client needs, as they may not come back for a while, if ever, thus the ability to have social workers and wellness counselors on site is highly beneficial. With influenza season almost under way, I continue to educate patients that it is important to obtain their influenza vaccines. I do this on an ongoing basis. I also recommend being up to date on tetanus/reduced diphtheria toxoids and acellular pertussis vaccine for those who patients whom it is appropriate (age 18-64). I also counsel patients regarding lifestyle modifications such as weight loss (esp. with BMI >30 – obesity in adults and >25 is at risk for the pediatric population), nutrition, exercise, tobacco cessation, and ETOH use. Several adult patients were seen with acute exacerbations of asthma, acute bronchitis, COPD, and URI. Many of those patients are smokers, who were advised to quit smoking and were asked if they were ready to quit yet. Exposure to second hand smoke is discussed in the pediatric office with all patients, but more in depth when children present with c/o related to asthma, bronchitis, URI, AOM, and cough. I have regular opportunities to practice independently both at HCA and at the Pediatric office. Each preceptor feels comfortable with my level of care and competence, and knows that I will ask questions when necessary. Additional opportunities to independently practice my skills will only enhance my clinical confidence and comfort level to practice more autonomously within my scope of practice after completion of the program.10/24/12 - Providing anticipatory guidance and counseling regarding multiple health issues and measures is something I find myself doing with most patients. In the pediatric setting, the most common form of anticipatory guidance and health counseling that I have had the opportunity to provide is during annual well-child exams, as it is during this exam that unknown health issues arise. During such visits I educate patients/families on the importance of age or risk appropriate screenings, including immunizations and growth and development expectations. At HCA, two patient examples stand out at this time. One patient was seen for follow up after a CVA. He had not been back to the clinic since his DC from the hospital almost 6 months prior! The patient was still a smoker with hypertension and was out of his HTN meds. I spoke in detail about the effects of hypertension and smoking, especially with his CVA hx. In addition to medication management for this patient, the effects of smoking on the body and how it affects the body’s ability to heal were discussed. The patient had other co-morbidities, including obesity and dyslipidemia, which provided a great opportunity to talk about changes in diet, exercise and lifestyle to increase the likelihood of weight loss, lower blood pressure and cholesterol, and prevent future CVA events. The other patient was a 53 y.o. female patient who was seen for a yearly well-woman exam. She had a palpable breast lump, had a family history of breast cancer, and had never had a colonoscopy; She also had not had a hysterectomy. Proper health counseling was done, including the need for a PAP, a home fecal occult blood test kit was sent home with the patient, a colonoscopy was discussed, and a mammogram was scheduled for the patient. I discussed the importance of doing self-breast exams monthly and how by doing a self-breast exam, the patient found this lump; since the patient had not seen a provider in several years, anticipatory guidance or health counseling related to other potential health risks, including dyslipidemia and hypertension. During our discussion, the patient recalled having dyslipidemia in the past, so I ordered lipid levels as well. I had a great discussion with the patient about what lipids were, what they meant and how diet, weight management and lifestyle changes could have a positive effect on lipids, as well as the other positive effects that lifestyle choices can have on health. In the pediatric setting, when we review BMI with patients and their families at annual exams, this is a great time to provide guidance and health counseling especially in regard to cardiovascular disease risk factors related to childhood obesity. Common areas of guidance for this population focus on weight management, exercise, nutrition counseling, and immunizations. The pediatric office also has a nutrition counselor and a weight management clinic that we refer patients and families to if they have a BMI over 30 and are receptive to the program. The American Academy of Pediatrics (AAP) guidelines are utilized and serve as a resource for this population, as well as the CDC immunization recommendations. I feel I need additional opportunities and practice to provide guidance independently to achieve a higher ranking. Frequently this guidance is provided in a joint care approach between my preceptors and me. 11/26/12- Since my last submission, I continued to provide individualized anticipatory guidance and health counseling for patients across the life span. Information gained via patient interviews, knowledge about human development, and epidemiology are some of the main factors that guide the development of anticipatory guidance and health counseling for patients across the life span. Anticipatory guidance is discussed frequently at the pediatrics office, as children are seen more regularly and reach developmental milestones more often. For example, children are seen at 1 week, 6 weeks, 2 months, 4 months, and 6 months of age after birth. They receive immunizations often and have “well-child” exams, and discussing anticipatory guidance is a major part of discussions with parents, especially new parents, because kids develop so rapidly. At HCA, I continue to counsel patients regarding lifestyle modifications such as weight loss (esp. with BMI >30 – obesity), nutrition, exercise, tobacco cessation, and ETOH use. Acute exacerbations of asthma, acute bronchitis, COPD, URI, acute pharyngitis and influenza are common conditions seen this time of year in both care settings. Smoking cessation, influenza vaccination, hand hygiene and pertussis vaccination were discussed regularly. I feel I have had well-rounded experiences and practice including having preceptors that allow me to provide guidance independently with little assistance. I am looking forward to moving into a role where the independent experiences will facilitate more clinical confidence.3.Prioritize differential diagnoses based on etiologies, □ □ □ □ xX risk factors, underlying pathologic processes and epidemiology for medical conditions I feel like I am meeting this expectation most of the time. I am able to identify etiologies, risk factors and underlying pathologic processes for medical conditions. I see a large population of patients with a history of hypertension, diabetes, hyperlipidemia at HCA. It is rare to not see a patient at HCA without at least one of those diagnoses. I have also dealt with recognizing risk factors for a variety of respiratory disorders including seasonal allergies, asthma and signs/symptoms associated with an URI and sinusitis. It is also the time of year when we will throw influenza and pneumonia into the mix as potential diagnoses as well. I have also evaluated multiple patients with new onset low back pain/lumbar back strain (847.2). In my readings and collaboration with my preceptor, the first line of treatment for low back pain injuries is NSAIDs, and the patient should remain active. Low back pain is the fifth most common reason for all primary care visits in the United States. According to the American Academy of Physicians (2007) guidelines on low back pain, clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain unless severe or progressive neurologic deficits are present. X-rays or MRIs should only be obtained with persistent (> 1 month) low back pain and signs or symptoms of radiculopathy or spinal stenosis. I inform the patient of evidence-based information and of the expected course (Most patients achieve 90% improvement within 1 month) and provide information about effective self-care options (NSAIDS, acetaminophen, heat packs).I have also had the opportunity to evaluate several patients with ankle and foot injuries. For example, I treated a 13 y.o. female on 9/13 at the peds office with left ankle pain, unable to bear weight, injured while doing cartwheel, + edema noted, neuros intact. According to the Ottawa ankle rules, because the patient had pain in the lateral malleolar zone, was unable to bear weight both immediately and in the clinic for four steps, AND had bone tenderness along the distal 6 cm of the posterior edge of the fibula and the tip of the lateral malleolus, an ankle x-ray was ordered to check for a fracture. Differential Diagnoses included: ankle sprain/strain, ankle fracture, foot fracture, foot sprain, foot pain. The x-rays were positive for a distal fibula avulsion fracture. The patient was splinted appropriately, given crutches and dc’d with FU with orthopedics. The Ottawa Ankle Rules are most appropriate in children over 6 and EBP supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot and has a sensitivity of almost 100%.In addition, I have evaluated several patients with various dermatological problems as well. Although my confidence is steadily improving, I still lack 100% confidence in evaluating dermatological problems. More easily identifiable dermatological problems that I have had the opportunity to diagnose during this rotation include skin tags (757.39), viral warts (78.1), shingles (53.9), poison ivy (692.6), psoriasis (696.1) and cellulitis (682.4). Other dermatological conditions like a “rash” are sometimes more difficult for me. Often times the patient is diagnosed with contact dermatitis (692.9), placed on topical corticosteroids or oral steroids, and antihistamines, and educated on returning to the clinic if not better in 7-10 days, sooner if worse. I have had some sense of relief to know that my preceptors do not always know what the “rash” is either. My preceptors and I have spent time looking up possible differential diagnoses for more difficult to diagnose dermatological conditions. With time and experience, I believe I will continue to develop more confidence with dermatological conditions. I do feel a clinical rotation with a dermatologist would be beneficial to all students in the MSN/FNP program, since dermatology issues are frequently evaluated initially in the primary care setting. As a result of the clinical experiences I have obtained thus far, I am beginning to feel more comfortable teaching patients about hypertension and the importance of medication adherence, and follow-up appointments. I also am developing more clinical confidence with management of asthma, bronchitis, URI, Sinusitis, and genitourinary problems, sprains/strains and fractures, and of course, dermatological conditions too.10/24/12- Prioritize is to arrange or do in order of priority or to organize or deal with something according to its priority. As I reflect on my growth related to this outcome, I feel more confident daily with prioritizing differential diagnoses based on etiologies, risk factors, underlying pathologic processes and epidemiology for medical conditions. This is significantly related to being able to tie in knowledge from previous courses in addition to prior professional experience. I feel like I am meeting this expectation most of the time by being able to independently identify etiologies, risk factors and underlying pathologic processes for medical conditions, frequently including hypertension, diabetes, hyperlipidemia at HCA. The challenge for this competency at HCA comes in narrowing down which co-morbidity is the priority, when many patients have several that are untreated! For example, I had a patient that presented for a follow-up on his dyslipidemia and to review lab results; the patient also had a hx of hypertension and presented with a BP of 210/136! This BP obviously needed to be addressed as a priority. The patient had been out of his BP meds and had neglected to call the provider for refills. The patient was asymptomatic, denied ha, dizziness or weakness. It was safe for this patient to restart his medications and have him return for a BP check. The potential differentials, had the patient been symptomatic might have included: hypertensive emergency, CVA, TIA, weakness, uncontrolled hypertension, to name the top priorities. This patient also has untreated mixed dyslipidemia by identifying high total cholesterol, a low HDL, a high LDL, and high triglycerides – which need to be addressed as well. The patient was started on atorvastatin 20mg daily. Another example of prioritizing differential diagnoses was a pediatric patient, 7 month old male, seen for cough, wheezing, irritability and up all night. Differentials included: croup, RSV, AOM, pneumonia, URI. Diagnosis was acute otitis media after further hx and exam. The problem visit allowed me the opportunity to select differential diagnoses appropriate for their chief complaint. The appropriate diagnosis was made after the exam, but I was able to think about all the potential diagnoses before entering the exam room. I am better able to differentiate acute health problems and chronic health conditions based upon the patient’s presenting risk factors and signs and symptoms. I continue to utilize reference materials (Epocrates, Up to Date, AHRQ) to remind myself of the pathologic process and epidemiology. In all, I feel I am able to piece the information together on the specified conditions, with some additional assistance from preceptors on more complex issues. I feel with additional independent practice in the clinical setting, I will rely less on resources and my preceptor for guidance.11/26/12- Being able to prioritize differential diagnoses requires an advanced level of assessment, knowledge of disease processes, and critical thought, evident as being able to sort through a variety of complex factors, and make decisions in the health care setting. Since my last submission, confidence in my ability to perform this competency has grown exponentially. Previously I had reported that the challenge for this competency at HCA was in narrowing down which co-morbidity was the priority when so many patients had several that were untreated. I feel more confident at this point than ever before in helping prioritize differential diagnoses and helping the patient decide which chief complaint is the priority as well. For example, if a patient presents for a follow-up appointment on DM, but they also have HTN and their BS readings and recent labs are acceptable, but their BP is elevated and they are symptomatic (HA, dizzy, weakness, SOB), then the HTN becomes the priority. Priority DD to consider in this case continue to include HTN, TIA, CVA, HA, and hypoglycemia. I still struggle a little bit to not address multiple issues with patients at HCA because I don’t want them to “fall through the cracks” so to speak. One thing that has helped is assisting patients to understand their role in facilitating self-care management. At the peds office, often times I would see more acute patients, and a common chief complaint is a sore throat- priority DD include acute pharyngitis, AOM, URI, Hand-foot-mouth disease, and mono. My clinical experiences at the peds office and seeing so many patients with sore throats have helped me better distinguish when I think it might really be acute pharyngitis. I am better able to identify pharyngitis even before the raid strep screen by using the triad of signs and symptoms that are classic strep and just having repeated exposure to the illness. With future diagnostic decisions, I will consider each differential and think about each of the factors in this competency, making sound decisions and avoiding assumptions as much as possible. I will continue to gain knowledge about medical conditions, and will rely on my knowledge and instincts to prioritize diagnoses in the future. Throughout this experience, I have used a variety of references to achieve this competency, including Ferri's Advisor, UpToDate, VisualDx, Buttaro, Epocrates and other tools for building differentials.________________________________________________________________________4. Perform comprehensive health history and physical exam □ □ □ □ □ x XX for patients across the life spanI feel like I am meeting this competency due to the number of exams I perform on a daily basis. Each patient is asked about personal medical and surgical history and medication history is also obtained. These are documented and reviewed at each visit. There is not always the opportunity to perform a comprehensive health history and physical exam, nor is it often appropriate depending on the patient presentation. It is rare that I would do a comprehensive exam during the “sick clinic” peds hours from 0800-0900 daily at the pediatric office. A comprehensive health history and PE includes timeliness, thoroughness of complete history which includes genogram or at minimum family history, social history, and all PMH. It also includes a thorough skin assessment. The best opportunities I have for the thorough exams are during well-child/yearly exams at the pediatric office and during “new patient” evaluations at HCA. I also see a large number of patients with chronic, uncontrolled DM and HTN. Those patients with DM get a foot exam at each visit and are asked about their last comprehensive eye exam as well – their DM meds are reviewed, as are any additional blood sugar readings that the patient may have been asked to bring for review. Medication management is a big part of managing chronic disease processes like DM and HTN. Those patients with HTN get a thorough comprehensive exam including but not limited to HEENT, cardiac, respiratory, GI, GU, psych. Neuro, and Musculoskeletal. Diagnostic tests including a CBC, COMP, Pro BNP, ECG, CXR, UA, may also be indicated.Multiple patients have presented at HCA for follow up on their HTN, and on arrival they have a BP of 230/110 or similar! If I were in the ED we would be treating that right away with IV meds. This type of BP reading is not unusual to see at HCA. Many times it is because a patient is out of their medications for several days. Most of the time the patient is asymptomatic as well and we typically refill their medications, discuss importance of not letting meds run out, we discuss financial needs to make sure meds are being taken as directed, lifestyle modifications, etc. If their BP was normal on their last visit and it was a recent visit with them taking their medications, we will have them track their BP measurements if possible, but also have them return to the clinic in a week for a nurse visit to have their BP checked, and again in two weeks for follow-up, sooner if they become symptomatic. Similar incidents happen with patients who have DM. Often times they present with blood sugars in the 200-300 range, sometimes higher; medication adherence is discussed, and we discuss whether or not they are checking their blood sugars as often as they should be. Again, patients seem to do okay if they have their medications and are adherent with their regimen, but a typical patient at HCA doesn’t always take their medications as directed, or follow their plan of care as directed. I see several patients a day with DM and/or HTN – we do our best at medication management and education and prescription assistance as much as possible. In addition, each new patient at HCA gets a comprehensive exam and other patients get a comprehensive exam as needed. Each pediatric patient gets a comprehensive exam at their well child yearly visits, and as needed. I can see why providers schedule more time with new patients, as a comprehensive exam visit is more time consuming than the problem focused exam, naturally. I had a 57 y.o. male pt come to HCA on 9/7/12, with a c/o low back pain – this was a chronic problem for this patient, and he was having a flare-up; the visit was more timely because he was a new patient to our clinic, and thus required more comprehensive evaluation, including personal and family health history, medications, social history and history of present illness. The diagnosis was still chronic low back pain, and PT was initiated, but since he was a new patient to our clinic, his initial visit was more timely, in order to help establish a baseline for future visits. I continue to improve in this area, mostly in the efficiency in which I perform exams. My head to toe assessment is more fluid and natural. It has taken some time to develop my own routine, but with the observation of different preceptors, I have been able to solidify my own exam style in a timely manner. I plan to continue to improve my efficiency in this area.10/24/12- As previously stated, I continue to improve in this area and exam efficiency is better each day. My head to toes assessment continues to feel more fluid and natural and I feel confident in my own systematic approach to the exam which is more solid now. The best opportunities I have for the thorough exams continue to be during well-child/yearly exams at the pediatric office and during “new patient” and yearly/annual evaluations at HCA. I was able to complete comprehensive health history and physical exams when performing yearly well-woman exams, which also included genital/pelvic exams with Pap testing on many patients. I have performed at least 12 more well-child exams in the pediatric setting since my last submission. The patients have varied in age, but overall, the fluency in which I perform these exams continues to improve, as does my confidence in feeling like I have not left anything out! Additional independent practice in this area has assisted me in achieving a higher ranking for this competency. I can continue to improve in efficiency as clinical rotations progress and I am closer to being more independent.11/26/12- Since my last submission, I continue to improve daily in this area and exam efficiency continues to improve. My head to toes assessments are feeling more and more second nature and I feel confident in my own systematic approach to the exam which remains solid. Comprehensive services for patients must include consideration of health history and thorough examination of the patient. I have performed comprehensive physical exams on patients from birth to 65 y.o. patients this semester, and have gathered comprehensive health histories through review of charts, records, and patient interviews. Repetition of an organized head to toe exam has enabled me to be able to gain confidence in my ability to perform a comprehensive exam in a timely fashion. Comprehensive exams are most often performed for health clearance for school, sports activities, or pre-employment, and also for new patients and routine, annual health maintenance. Pediatric patients have yearly well-child exams, and often more frequently during the early years. While there is always room for improvement, as a novice NP, I will be confident I can perform thorough comprehensive exams on male and female patients, with proper techniques and up to date guidelines. Again, additional independent practice in this area has assisted me in achieving a higher ranking for this competency. I am proud that I have developed my own systematic approach to doing a comprehensive exam that is thorough and has become more efficient as I step out of clinical practice and into more independent practice as a “real” provider of comprehensive care!________________________________________________________________________5.Perform problem focused health history and physical exam □ □ □ □ □ xXXfor patients across the life span Mostly I perform a problem focused health history and physical exam as indicated. It is always important to review health history, meds and allergies when diagnosing and prescribing meds, so the history is important. The majority of exams I perform are problem focused around the patient’s chief complaint. I am able to independently obtain a brief health history without the support from my preceptor. I have adopted a systematic routine for asking initial questions prior to beginning my physical examination. In most situations, I am able to formulate basic differential diagnoses, perform the initial assessment, develop differential diagnoses, order the appropriate diagnostics, and determine treatment options. Once I have a care plan in place, I present my findings verbally, and my preceptor and I discuss any necessary additions/changes, which are fewer than ever!So far during this rotation, I have had the opportunity to do problem focused exams of HEENT/ Respiratory (URI, strep throat, sinusitis), musculoskeletal (shoulder strain, ankle sprain, back pain, knee pain, fractures), genitourinary (UTI, pelvic pain), Dermatology/Integumentary (rash, cyst, abscess, warts), etc. I feel comfortable that I have assessed each body system and a complaint that deals with each system on more than a few occasions. I certainly haven’t seen it all, but have had the opportunities to see a lot. To become more proficient in meeting this outcome in future practicums, I’m hopeful to have continued practice with large number of patients of all age groups, gender, cultural and ethnic backgrounds. My goal for the remainder of this rotation is that I would like to improve my efficiency.10/24/12 - My performance in completing a problem-focused health history and physical exam to formulate a differential diagnosis has become more organized and systematic since the beginning of this clinical experience. I have gained significantly more confidence in performing a problem-focused physical exam and health history, as well as in interpreting my findings, to develop appropriate differential diagnoses. I continue to independently perform problem-focused health history and physical examinations without support from my preceptor. I am able to be more concise in narrowing my differential diagnoses for a final diagnosis. I do require some support with utilizing exam techniques not frequently used, specifically eye examinations using the wood’s lamp or slit lamp. Problem focused areas I have been able to evaluate include HEENT (CC: eye pain, ear pain, sinus pain/congestion, sore throat, scalp wounds and rashes, mouth pain, decreased hearing, headache), with final diagnoses including pharyngitis, AOM, sinusitis, URI, conjunctivitis, cerumen impaction, otitis externa, and allergic rhinitis; Respiratory (CC: fever, cough, wheezing, SOA) with final diagnoses including acute bronchitis, CHF, URI, pneumonia; Cardiac (CC: chest pain, cough, rib pain), Musculoskeletal (back/wrist/elbow/ankle/foot/knee/hand/neck pain), GI//GU (abd pain, n/v/d, rectal pain, dysuria, male/female genitalia c/o), Dermatology/Integumentary (rash, cyst, abscess, wart, foreign body removal), etc. I continue to feel comfortable that I have assessed each body system and a complaint that deals with each system on more than a few occasions. My confidence continues to improve in performing problem-focused exams and I am more efficient in this area. When I am stumped on a diagnosis or need assistance with an exam, I often refer to my apps on my phone, including Epocrates, VisualDx, Medscape or WbMD. I also use my Sanford guide to antimicrobial therapy and my Tarascon pocket guide frequently when determining the treatment plan. To become more proficient in meeting this outcome for the remainder of this rotation and as I begin my career, I’m hopeful to have continued practice with large number of patients of all age groups, gender, cultural and ethnic backgrounds. 11/26/12- As previously stated, and even since my last submission, my performance in completing a problem-focused health history and physical exam to formulate a differential diagnosis has become more organized and systematic with each clinical experience. I continue to gain significantly more confidence in performing problem-focused physical exams and health histories, as well as in interpreting my findings, to develop appropriate differential diagnoses. Problem-focused health history and physical exams are appropriate when an established patient is seeking medical care for an acute problem or following up on a specific problem or health concern. My background as an emergency room nurse has enhanced my ability to be problem-focused during a patient visit, and I have had the opportunity to practice on a number of patients coming in for acute issues in the current clinical settings. For example, my confidence continues to improve in performing problem-focused exams such as pelvic exams during WWE. Ankle sprains, back pain, sore throat, ENT, dysuria are all common complaints I feel comfortable with. I still feel a little rusty with rashes, unless it’s shingles or a strep rash or poison ivy. I did get to see Pityriasis Rosea for the second time at the peds office. I think it will be much easier to recognize now! I continue to refer to my apps on my phone, including Epocrates, VisualDx, Medscape or WbMD when necessary, but feel as if I used my Sanford Guide to Antimicrobial Therapy and my Tarascon pocket guide less frequently when determining the treatment plan. I have become more proficient in meeting this outcome and as I begin my career, I’m hopeful to have continued practice with large number of patients of all age groups, gender, cultural and ethnic backgrounds. ________________________6.Apply diagnostic reasoning and critical thinking □ □ □ □ xXXin clinical decision-making and development of a treatment planDiagnostic reasoning is a critically important skill that involves intuitive and analytical processes used to make a clinical decision in regard to a developing a patient’s diagnosis and treatment plan. Through the course of this practicum, as well as earlier practicums, I have had the opportunity to develop the skill of diagnostic reasoning to assist me in making clinical decisions about the diagnosis and treatment plan for over 600 patients. Overall, I feel I am doing quite well with clinical decision making and plan development. I often use Epocrates or Medscape, as they have the most up to date evidence based treatment plans and diagnostic tests and differentials. I believe my ability to demonstrate diagnostic reasoning in clinical decision making has improved. Part of the improvement can be attributed to an increased sense of confidence in my assessment skills as well as to more experience. In order to independently meet this competency by the end of the semester, I will need to continue with my current course of action and practice decision making and plan development. I need to also start practicing as if I am on my own, so I don’t get used to collaborating with another provider after each patient encounter to determine all of the differential diagnoses and treatment options.10/24/12- Diagnostic reasoning continues to be a critically important skill that involves intuitive and analytical processes used to make a clinical decision in regard to a developing a patient’s diagnosis and treatment plan. Since my last submission, I believe my ability to demonstrate diagnostic reasoning in clinical decision making has improved. Part of the improvement can be attributed to an increased sense of confidence in my assessment skills as well as to more experience.Examples include the treatment of depression, hypertension, and hyperlipidemia, as well as respiratory conditions such as asthma, croup, bronchitis, pneumonia and pharyngitis. I have been able to distinguish key assessment findings that support the above diagnoses such as sleep disturbances/suicidal ideation, elevated blood pressure, and abnormal lipid profiles, cough/wheezing/dyspnea, and sore throat/cervical adenopathy/exudates/fever. I need to continue to get exposure to a variety of clinical situations to continue practicing my diagnostic reasoning, clinical decision making, and skills in treatment plan development. I feel confident in frequently seen conditions such as those listed above. It’s like using an algorithm for each chief complaint, but you have to add critical thinking to each patient to make sure something doesn’t get missed, and you have to have confidence in your decision making abilities. Critical thinking is a learned behavior and continued experience in being able to critically analyze a problem using knowledge from EBP and the patient’s history and physical exam will only enhance this skill. To continue my skill development I feel I need further practice and exposure to a variety of clinical situations that challenge my decision making and development of a treatment plan. 11/26/12 - - Nearly all clinical situations involve some degree of diagnostic reasoning and critical thinking. These are critical components in both processes of forming diagnoses and developing treatment plans. There are many different approaches to clinical decision-making, and the practitioner should be aware of, and comfortable with his or her diagnostic reasoning and critical thinking skills. Diagnostic reasoning continues to be a critically important skill that involves intuitive and analytical processes used to make a clinical decision in regard to a developing a patient’s diagnosis and treatment plan. Since my last submission, I have obtained repeated exposure to a variety of clinical situations that challenge my decision making and development of a treatment plan. Clinical decision making is also critical decision making. It is important to make the safest, most effective decisions for the patient. Examples of this from my current practicum are represented by the decisions about when to refer patients, when to recommend that patients seek emergency care, and with what frequency they should follow-up. I had a female patient towards the end of my practicum that presented with flank pain intermittently for several days and dysuria. Her DD included UTI, pyelonephritis, kidney stone, appendicitis. Her POC urinalysis was negative except for blood. My most likely DD was kidney stone. I had to make the decision on whether or not to send her to the ED or order a CT and give her po meds for home. She reported her pain an 8 on a 0-10 scale and she was pale and restless. I discussed the options with the patient. We decided to try outpatient treatment first. I scheduled her an outpatient CT, then gave her RX for Zofran and Lortab, which she was to fill prior to her CT and take the first dose, since we do no dispense those meds through HCA. She followed the orders as directed. She ended up with a 4mm kidney stone. She did not have to go to the ER for treatment. It feels like another life saved- at least a lot of money saved in lots of areas just by having an uninsured patient avoid the ER if possible. I will continue to strive to become an expert nurse practitioner by advancing my ability to perform these skills consistently, and will continue to stay abreast of current guidelines and recommendations. Well-validated clinical guidelines and diagnostic tools are accessible, and have been useful in helping me achieve this competency. I have accessed guidelines and tools through many major organizations, such as the American Diabetes Association, as well as through government-supported sites, such as the AHRQ and USPTF for guidance. Tools are helpful, as is consideration of social values and instinctual signals. Experience = mastery!7.Implement screenings appropriate to differential diagnoses □ □ □ □ x XXI feel confident when it is appropriate to recommend screenings to patients. For example, if I find a patient is hypertensive (BP > 140/90 on at least 2 separate occasions), then I will discuss a treatment plan and follow-up. I also discuss risk factors and lifestyle modifications (weight loss, restrict sodium intake, etc.); I also recommend they check their BP at least once a day, same arm, same time of day, and record measurements to bring with them at their next visit. We distribute BP cuffs to patients if we have some available, and we also encourage taking BP’s at grocery stores or pharmacies as needed. I also ask about family hx of HTN, heart disease, etc. and keep in mind guidelines for TSH screening and lipid disorders, COPD, and DM. I also screen for thyroid disorders as well, and we may add a TSH and free T4 to their labs if we feel they are at risk or if we think hyper/hypothyroidism is a potential differential dx. I had a 43 year old patient this month that had a TSH in the upper 400’s! I’m not sure I had ever since it that high before. She had been off her levothyroxine for 6 years! She had started back on her medication about 1 month prior to this visit and her TSH was down to less than 200. I increased her meds and will have her follow-up again in 2-4 weeks, sooner if worse or is she develops new symptoms. The patient reported she hadn’t had this much energy in years! Next, I had a 32 y.o. female patient who presented with heavy vaginal bleeding; DDx included pregnancy related bleeding, dysfunctional uterine bleeding, and genital tract neoplasm. Screening tests included pregnancy test (negative), CBC and coagulation studies; all tests were normal, and pt was Dc’d with Dx of Dysfunctional Uterine bleeding. During the HPI and ROS, pt had reported that she hadn’t had a PAP in more than 12 years! The patient was informed that women between the ages of 30 and 65 should have a Pap test plus an HPV test every 3-5 years (ACS, 2012). Pt stated “I know….that’s what I was scared about today”. The patient scheduled a Pap before she left the clinic Based on my current and past experiences, I feel comfortable with this competency.I continue to feel more confident in recommending appropriate screenings based on differential diagnoses This last clinical experience has enabled me to become much more familiar with the recommended guidelines for screening for colon cancer (colonoscopy at age 50), breast cancer (mammogram at age 40 unless family hx, then sooner), STI’s (when sexually active, and when changing partners or with unprotected intercourse), and cervical cancer (age 21 or within 3 years of becoming sexually active, whichever comes first, then every 2-3 years after having 2 normal Paps in a row, until age 65 or until Hyst.). Again, knowledge gained from previous courses and clinical experiences has been instrumental in knowing what the recommended screening guidelines are and where to find them. With each passing day, the recommended guidelines come from memory, instead of me having to look them up. I hope to continue to build on my knowledge base and continuously work on putting it all together really nicely. 10/24/12- Screenings are defined as a means of accomplishing early detection of disease in asymptomatic people. Screenings are a form of secondary prevention. I continue to recommend appropriate screening procedures for common conditions seen in the clinical setting. Examples include blood pressure screenings on all patients, yearly mammograms for women starting at the age of 40, PAP tests 3 years after a woman begins having vaginal intercourse or age 21, whichever comes first- following ACOG guidelines after age 30; PSA beginning at age 50 (45 for African Americans and those with a positive family history); HgbA1c every 3 months for non-controlled diabetics, annual lipid profiles for dyslipidemia patients, annual TSH, and discussion of respiratory function when appropriate as well. Since my last submission I feel better versed in the frequency of such screenings and need to look up information on a less frequent basis. I utilize the AHRQ app if I’m not sure of current recommendations: the app retrieves recommendations from the USPSTF Preventive Services database and is age and gender specific. For example, I had a 53 y.o. female patient for a well woman exam – still had all her female parts, no labs in 3 years, family hx of breast ca, no PAP or mammogram since “can’t remember” – pt had PAP, mammogram, colorectal FOBT kit, lipids, and TSH. For pediatric patients, screening questionnaires for early autism detection are done routinely, as well as BMI measurements in older children and adolescents. To continue to increase my rating and proficiency I feel repetition is necessary via application of my skills in the clinical setting. Independently recalling the information during patient encounters will also assist with my proficiency development, in addition to knowledge gained throughout my educational courses and through prior practical experiences.11/26/12 - Screenings are defined as a means of accomplishing early detection of disease in asymptomatic people. Screenings are a form of secondary prevention. I continue to recommend appropriate screening procedures for common conditions such as CHF, DM, HTN, CAD, Hyperlididemia, as well as FOBT, Mammograms, PAP and screenings seen in the clinical setting, to name a few. A great example is ordering either a diagnostic or screening mammogram based on needing a routine screening mammogram, or finding a lump on a CBE that needs a diagnostic mammogram. Some examples of the screening recommendations I use are those put out by the American Cancer Society, the CDC, American Heart Association, the American Diabetes Association, the American College of Ob/Gyn, The American College of Cardiology, JNC 7 recommendations, NIH-ATP III Guidelines, ADA Standards of Care, and apps like the Framingham CHD risk calculator, Epocrates, AHRQ, and UpToDate reference material. As I begin more independent practice, I will stay current with the latest research recommendations so I am more able to independently recall the information._____8.Initiate diagnostic strategies appropriate to differential □ □ □ □ X XXdiagnosesI have had the opportunity to recommend several diagnostic strategies while at HCA and Pediatric & Adolescent Medicine (PANDA). I feel fairly confident when to order x-rays, lab work, and EKGs. I am not completely independent in this competency, but feel more confident each day. I also feel more confident on when a referral to another provider is appropriate, or when ordering a CT/MRI is necessary. HCA has specialists (surgeons, family practice physicians, hospitalists, cardiologists, neurologists, pulmonologists, nephrologists, gynecologists, and more) that volunteer regularly, so just figuring out who the volunteer base is helps with referring patients to the appropriate person. At HCA we can perform point of care (POC) testing for UA’s and Urine PG tests and influenza (seasonal). For other lab work, we send the patient to LMH for same day testing for labs and can schedule outpatient radiology and other testing as appropriate (X-ray, US, CT, MRI) at LMH- they provide these services free of charge for our patients as part of their charity care. For basic labs and x-rays, we usually have those results on the same day we order them. At PANDA, we have POC testing for UA’s, Pregnancy UA’s, and rapid strep and influenza. Other tests are ordered on an outpatient basis usually at LMH (insurance dictates where sometimes) – most basic labs and x-rays are ordered same day (11 y.o female sent to LMH for ankle x-rays, then reported back to office and we were able to view x-rays immediately). As always, looking at urgency, referrals, follow-up and necessary POC testing options and patient insurance and financial status are also pertinent when being prudent!I will continue to seek opportunities to learn more about the appropriate lab work to order based on my differential diagnosis.10/24/12- I continue to seek out learning opportunities and have had positive learning experiences since my last submission. One example includes participating in the care of patient with new onset HTN who had slightly elevated creatinine (otherwise normal lab values), normal renal US, and history of arthritis (on NSAIDs) with no history of CAD or diabetes. I recommended HCTZ—no ACE/ARB due to NSAID usage. Provided education to patient as to what class (Diuretic), take in morning—may increase urination, prevent hypokalemia by eating diet rich in potassium, and prevent orthostatic hypotension by rising slowly. Patient to return to clinic for re-assessment of HTN and labs including glucose, potassium, lipid levels, and renal function. Another example is a 12 y.o male patient with a cough, wheezing, fever, ha; denies n/v/d, normal po intake – DD include URI, asthma, pharyngitis, bronchitis, OM, pneumonia, mono; pt. is given albuterol tx in office with some improvement; CXR, EBV, CBC, COMP, rapid strep ordered (neg); Dx is pneumonia; tx plan includes albuterol inhaler q4 hours at home, azithromycin x 5 days, Mucinex, Tylenol and ibuprofen for fever/comfort, encourage fluids.The same examples stated above continue to apply. I am feeling more confident everyday on my diagnostic strategies and appropriate differential diagnoses. At this point, I feel it is just a matter of efficiency and confidence, which will come with time. I will continue to seek out opportunities for learning and work on efficiency. 11/26/12- Diagnostic strategies differ from screenings in that they are initiated when a problem has been identified, (as opposed to routinely, or on a schedule) and are used to help rule in or out various differential diagnoses, to determine what is going on, and to not miss serious, or potentially life-threatening conditions. I have been able to independently determine diagnostic strategies to help distinguish appropriate differential diagnoses. I have had the opportunity to recommend several diagnostic strategies while at HCA and Pediatric & Adolescent Medicine (PANDA). Examples include ordering an ankle or x-ray in a pt meets Ottawa ankle rule criteria. I also had a 2 y.o. male pt in the pediatric setting who had a c/o new onset limp over the last 2 weeks; no injury or trauma, denied pain. Hip x-rays were ordered to rule out hip dysplasia. Labs were ordered to rule out any malignancy, then pt will be sent to Children’s Ortho for evaluation if tests ordered were negative. At the time of my last clinical rotation at the peds office I was aware only of negative x-rays. Another example of this competency is when I had a female in her 30’s with right flank pain. POC Urine dipstick was negative except for blood, which is a common finding in kidney stones, and urine pregnancy test were negative. Based on c/o right flank pain, denied urinary s/s, denied pelvic pain, dc or bleeding and a negative pg test, DD was most likely kidney stone – confirmed with a CT- best diagnostic test to diagnose kidney stones. Again, I mostly Ferri's Clinic Advisor, UptToDate, Epocrates, as well as others mentioned above (in #7) for reference and guidance for knowing what diagnostic strategies are appropriate for making or ruling out various diagnoses. At this point, I feel more efficient and have developed more confidence over time. I will continue to seek out opportunities for learning as I begin as a novice NP. _____________________________________________________________________________9. Develop and evaluate the plan of care utilizing □ □ □ □ x XXevidence-based practice.I feel I am able to develop and evaluate the plan of care utilizing evidence-based treatment information in patient care. Guidelines I use in this practice include the most up-to-date evidence-based practice published. I use Epocrates, Medscape, WebMD, Up to Date, Sanford Guide to Antimicrobial therapy (2011), and Tarascon’s Pocket Pharmacopoeia (2011 Ed.) on a daily basis. I have discussed the over-use of antibiotic prescription on several occasions with my preceptor and with patients.I have confidence in discussing appropriate treatment based on evidence based practice with my preceptors. Such examples include whether or not to treat a patient with a diagnosis of acute pharyngitis who has a negative rapid strep test with antibiotics. One such example is a 21 y.o female patient who presented with a CC of Sore throat x 1 day; no fever, no cough, no anterior cervical lymphadenopathy and in no distress. A rapid strep test was completed per the patient request, which was negative. According to the CDC guidelines on adult appropriate antibiotic use (2009), Group A beta hemolytic streptococcus (GABHS) is the etiologic agent in approximately 10% of adult cases of pharyngitis. The patient was told that the large majority of adults with acute pharyngitis have a self-limiting illness, which would do well with supportive care only and that the benefits of antibiotic treatment of adult pharyngitis are limited to those patients with GABHS infection. It was suggested to the patient to try appropriate doses of analgesics, antipyretics and other supportive care, like warm salt water gargles and throat lozenges. The patient verbalized understanding and agreed with the plan of care.One thing I have learned throughout my clinical experiences and my experience as a nurse, “Is the test result going to change your plan of care? If not, why do the test?” So, I do consider if the testing is going to dictate my plan of care. Another example is seeing a patient for an acute Upper Respiratory Infection. I am not inclined to put the patient on antibiotics; I offer supportive care measures and educate the patient on the course and duration of illness. Per EBP and the CDC guidelines on treatment of URI, I tell my patients “Antibiotic treatment of nonspecific upper respiratory infections in adults does not enhance illness resolution or prevent complications, and is therefore not recommended.” (CDC, 2012). Generally, patients agree with supportive measures and the recommended plan of care. I take this approach both at HCA and at PANDA and my preceptors and patients are supportive of the plan of care.In discussing which sources were utilized to frequently access practice guidelines, I mainly use information from the National Guideline Clearinghouse (ARHQ), the CDC website, Buttaro, Epocrates, and the Sanford Guide to Antimicrobial therapy (2011). Drug interactions and dosages are researched mainly using Epocrates and the Sanford guide, as well as the Tarascon pharmacopeia guide (2011) when writing prescriptions.I believe practicing utilizing the most up to date EBP guidelines in the clinical setting is critical in the effort to provide the best and safest care possible. I feel I routinely meet expectations with minimal support from my preceptors by routinely utilizing EBP information10/24/12- Since my last submission, I have continued to develop and evaluate the plan of care utilizing evidence-based treatment information in patient care. I continue to use the same resources and EBP guidelines as mentioned above. I continued to review USPSTF recommendation for screening mammograms and pap smears with female patients. Evidence-based treatment information is also provided for patients with HTN using the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines. Reviewed lifestyle modifications: weight loss with target BMI < 25, limit alcohol intake (men < 2 drinks/day and women < 1drink/day), aerobic exercise 30 minutes/day, <1.5 g of sodium/day, stop smoking, DASH eating plan, and adequate dietary potassium (>3500 mg/day) in patients with normal kidney function. Taught Thiazide diuretics preferred for initial therapy in stage 1 HTN—advantages and disadvantages. Throughout my time in this clinical setting I have increased my knowledge of evidence-based treatment information in patient care. As I approach graduation, additional practice and independence in the clinical setting will facilitate confidently applying my skills with limited guidance from a preceptor. 11/26/12- The plan of care for both acute and chronic conditions, and for all interventions should be both evidence-based and effective. I continue to feel I am able to develop and evaluate the plan of care utilizing evidence-based treatment information in patient care with greater confidence and competence. Guidelines I continue to use in this practice include the most up-to-date evidence-based practice published. I have been able to provide consistent recommendations based on EBP guidelines. This competency was demonstrated by the use of evidence-based guidelines in developing a plan of treatment for several patients. An example is developing a plan of care for a patient with HTN. Based on JNC VII recommendations, stage 1 HTN should be treated with lifestyle modification (dietary and exercise education), and a thiazide-type diuretic like HCTZ. I remain confident in discussing appropriate treatment based on evidence based practice with my preceptors. A CC of a sore throat remains one of the top chief complaints seen in the peds office, esp. this time of year. I am more comfortable evaluating sore throat as a chief complaint, and consider the five cardinal signs of strep throat (fever over 101, sore throat without coughing, sneezing or other URI s/s, cervical lymphadenopathy, tonsillar erythema/exudate, and maybe a generalized rash) during my examination, which is usually right on. Although we still perform rapid strep screens frequently, you can usually tell on exam if a patient has strep or not. In the peds office recently, I had 2 such patients who were “textbook” PE presentations of pharyngitis, who both tested positive on rapid strep tests. They were subsequently started on appropriate doses of Amoxicillin. The other rapid strep tests were initially negative, and that also coincided with their PE; they were encouraged to utilize supportive care measures and were educated on the course and duration of illness, per EBP and the CDC guidelines on treatment of URI. I continue to use Epocrates, Medscape, WebMD, Up to Date, Sanford Guide to Antimicrobial therapy (2011), and Tarascon’s Pocket Pharmacopoeia (2011 Ed.) on a daily basis, as well as AHRQ's National Guideline Clearinghouse. As I have gained more experience, I have utilized Tarascon and Sanford’s Guide less often for more common diagnoses. __________________10. Prescribe medications based on cost, diagnoses, □ □ □ □ x XXefficacy, safety, and individual patient needsAt HCA, meds are prescribed based of diagnoses, but a patient need sometimes outweighs the medication prescribed – we always use the $4 list from local pharmacies first when possible. We also place patients on meds they can usually receive on the prescription assistance program (PAP) if it isn’t on the $4 list. There are also some meds that we use the cheapest in the class of medications if they can’t get it with PAP or the $4 list. You would think this is how meds are prescribed all the time for everyone, but not so much! I had a 41 y.o. female pt on 9/13/12 at HCA with dx UTI- was going to give her Bactrim DS BID x 14 days; told her to follow-up the following Monday if she wasn’t better; she reported that she wouldn’t be able to get the RX filled until the following Friday when she got paid, and also reported that she didn’t have electricity either at the time. The patient had also previously been admitted to the hospital for 6 days 4 months prior to now for pyelonephritis. I arranged for the patient to get Cipro 500mg BID for 7 days through a local pharmacy that had an assistance program and would cover the cost of the RX. With the patients financial needs and hx of recent hospitalization, I made a choice to change her to another RX that would be free for her and maybe offer better compliance with a shorter duration, and according to Epocrates (2012), a 7 day course of oral Cipro is more effective that a 14-day course of Bactrim in a complicated outpatient case. 10/24/12- I continue to see the same conditions as described above and am able to identify appropriate families of medications for given conditions. I feel confident with prescribing classes of medications, but still have some challenges, especially at HCA, when deciding which medication in a class to prescribe – mostly in the statins- there are so many, but do you write for simvastatin, atorvastatin, or lovastatin or pravastatin??? Typically at HCA we prescribe atorvastatin because it is on the $4 list, while simvastatin is $12 and others go up from there. Prior to this clinical rotation, I was not as familiar with pricing of meds, but it has been great to commit some of the pricing to memory – I think it benefits everyone – if you can tolerate the med, side effects, etc. At the pediatric office, we are beginning to see more strep throat as the fall/winter time approaches. Amoxicillin is still first line of treatment for strep and AOM (unless allergic to pcn). Additionally, specific medications that fall outside my comfort zone and that I do not immediately recognize, I look up in resources such as Epocrates. Continued exposure will assist in development of my knowledge base and proficiency that will help me to practice more independently.11/26/12- Prescribing medications based on cost, diagnoses, efficacy, and individual patient needs means considering multiple factors at once when choosing a medication, and individualizing the decision to prescribe. What is most important for one patient may be less so to another, and making the decision about which pharmacological product best fits the defined criteria to order for a patient, requires careful weighing of risks and benefits. It is often helpful to review what medications patients have taken in the past, and include this consideration of what has worked, and what has not, as well as what is indicated and what is affordable. All of the adult patients I am seeing in this clinical experience are not insured, which makes prescribing much more difficult. I continue to utilize the $4 medication list for most patients, when applicable. I have also learned to utilize more resources such as Prescription assistance programs. There is also a website called that tells you how much rx are at various places, and has coupons you can print off for the patient, to make it cheaper. It is accurate and up to date. We use it frequently at HCA for our patients when needing to RX more expensive meds sometimes, or trying to help the patient decide where it is cheapest to get filled. I plan to utilize this website to help my patients in practice as well. With more experience and confidence, I continue to be more comfortable in identifying appropriate classes of medications. Repeated exposure in clinical settings and reviewing my pharmacology references and notes has helped me develop my knowledge base and proficiency. There will be a constant need for staying informed as mew medications come on the market and patents expire, making the existing medications cheaper at times. Continued exposure as a novice NP will assist in development of my knowledge base and proficiency that will help me to practice more independently.____________________________________________________________________________11. Perform medical and surgical procedures as appropriate X X □ x □ □I have had the opportunity to do a couple of CBEs at HCA. I have also removed skin tags. If female patients are over 40 y.o. They are referred to the Health Department for their PAPs. Many patients are also referred to the Douglas County Health Department for STI screenings. We also set up FU with some volunteer physicians for toenail removal and skin tag removal, etc. At PANDA, I had the opportunity to drain (using a burr) a subungual hematoma on a great toe of a 2 y.o. male who dropped a weight on his great toe. While I have not yet had many opportunities during this rotation to do medical and surgical procedures, I have had ample opportunities for medical and surgical procedures during previous clinical rotations- both in the family practice setting, the OB/GYN setting, and in an urgent care clinic. As always, obtaining additional exposure with increased independence will assist in me mastering those skills. To fully meet this competency by the end of the semester, I will seek more opportunities to perform procedures and continue to practice when the opportunity arises.10/24/12- I continue to have opportunities to perform CBE and PAP procedures at HCA. Since my last submission I have not had additional opportunities to perform additional medical or surgical procedures at either the pediatric or HCA clinical setting. I did have the opportunity to observe twin birth by cesarean section during my pediatric rotation, as my preceptor was the pediatrician on call and attended the birth and did the newborn assessments. In my current job in the ED setting, I have multiple opportunities to observe multiple procedures on a regular basis, including suturing, abscess I & D, pelvic exams, and radiology interpretation. I fully understand that this question is asking about this particular clinical rotation, however, I want you to be aware and understand that I have had multiple opportunities in the past to perform certain procedures and to currently observe procedures through my position in the ED, so I do not feel totally “green” so to speak about feeling knowledgeable about medical or surgical procedures. I will continue to seek out opportunities to perform procedures and continue to practice when the opportunity arises.11/26/12- Common medical and surgical procedures performed by advanced practice nurses in the outpatient/primary care setting include point of care urinalysis, collection of specimen for culture, rapid strep screen, electrocardiogram, assessment of peak flow meter, pelvic exam with collection of specimen, incision and drainage, and suturing, to name a few. I continue to have opportunities to perform CBE and PAP procedures at HCA. Since my last submission I perform POC testing, including collection of cultures for rapid strep analysis, UAs, Urine pregnancy testing, and vaginal cultures when necessary. I have not had additional opportunities to perform additional medical or surgical procedures at either the pediatric or HCA clinical setting, with the exception of collecting specimens for testing. As I start my NP career, I will continue to seek out opportunities to perform procedures and continue to practice when the opportunity arises. I am not timid or hesitant to do procedures, and welcome new opportunities as they arise. When I am not familiar with a procedure, am doing something for the first time, or am out of practice with a certain procedure, I will be sure to reference a good procedural guide, such as the book 'Common procedures in primary practice', or look it up in some other way for refreshment. __________________________________________________________________________12.Interpret patient responses to treatment and recommend □ □ □ □ X XXchanges to the treatment plan as indicatedIn my pediatric setting, I see acutely ill patients at the “sick clinic” every morning, and their response to treatment is sometime fairly rapid. And because of the nature of that being an “acute care setting”, I often don’t see the patient again for follow-up for the same complaint, thus assuming the patient is improved! All of the acute patients are encouraged to return if not improved or if worse. When I see patients back for follow up at HCA, I can interpret their response to treatment being a positive one if their BP or DM is better controlled, or I can make further changes as needed. I had a patient with dental pain at HCA, put them on Pen VK. I saw the patient again a few weeks later for a different complaint, but the patient reported the dental pain was improved and the patient had scheduled an appointment at the Douglas County Dental Clinic. A sign of improvement! To continue improving my scope and depth I plan to continue utilizing resources to answer my questions regarding treatment, increase my knowledge base via course work, and learn from my mentor’s examples.10/24/12- In order to continue to interpret patient responses to treatment and recommend changes to the treatment plan as indicated, I persistently utilize resources to answer my questions regarding treatment, increase my knowledge base via course work, and learn from my mentor’s examples. I continue to see pediatric patients in the “sick clinic”, which makes it difficult to evaluate their response to treatment when I am not there on a daily basis and I may not see them for follow-up. However, it is standard to tell all of our patients to return in 2-3, or 5-7, or 7-10 days (common FU plan), if not improved, sooner if worse. Usually if there is an unusual case presentation I will ask about response to the treatments we provided. At HCA, it I treated a 59 y.o. female with a cough, fever, chills, difficulty breathing and chest tightness. She was given an albuterol nebulized treatment in the office, which she noted an improvement afterwards. She was then dx with pneumonia and given azithromycin RX for her pneumonia. I sent her for a CXR, which confirmed the dx of pneumonia. I haven’t seen the patient back at HCA since the dx, but was able to evaluate the effectiveness of the breathing treatment given in the office, and felt comfortable with the treatment plan. The patient was instructed to return to the clinic if she worsened, and she didn’t return, so I can only assume she improved! To continue improving my scope and depth I plan to continue utilizing resources to answer my questions regarding treatment, increase my knowledge base via course work, and continue to learn from my mentor’s examples.11/26/12- In order to continue to interpret patient responses to treatment and recommend changes to the treatment plan as indicated, I persistently utilize resources to answer my questions regarding treatment, increase my knowledge base via course work, and learn from my mentor’s examples. At this point, I have had limited ability to follow-up with patients based on the amount of time spent in the clinic. Additionally, the client population at HCA is more likely to “no show” or cancels appointments, making FU more difficult. HCA currently calls all patients and reminds them of appointments, and makes follow-up phone calls as well, pending being able to reach the patient. Examples of patients I have had the opportunity to follow-up with in this clinical experience include patients with uncontrolled diabetes, ongoing pain, and hyperlipidemia. A previous patient with elevated cholesterol, LDL, and triglycerides was asked to return to the clinic in three months to evaluate response to simvastatin. He had overall reduction in his lipid panel, and the dose of simvastatin was not adjusted. He was asked to return at 6 months for another evaluation. I had a patient who had recently had his HCTZ increased to 25mg for HTN, and when we evaluated labs, his K+ was 3.2. The patient had a previously normal K+ before, and was on 12.5mg of HCTZ and a potassium supplement at that time. The patient’s HTN was still not under proper control. I decided to lower the HCTZ back to 12.5mg for the time, add K+ 20meq daily, and added lisinopril 5mg daily, with a return appointment in 2 weeks. The patient was to have K+ level repeated and keep a daily BP log. At the peds clinic, we have all patients with AOM dx an abx treatment follow-up in 2 weeks for a recheck, sooner if worse. In the future, when I am the one responsible for the care of very ill patients, I will need to establish a level of comfort, deciding how and when to follow up for reevaluation and interpretation of response to treatment. Treatment algorithms are helpful in organizing care and can guide the practitioner in making logical changes to the treatment plan, as indicated. ____________________________________13.Document using professional terminology, □ □ □ □ X X Xformat and technology (i.e.: ICD9, E/M coding, CPT)While at HCA, we use Cerner computerized documentation in Power Chart. You have to select the right template diagnosis (E.g. Well woman exam, abdominal pain, hypertension, general exam, diabetes, sore throat, headache, back pain, etc.) and you have to select the proper E/M code, and CPT codes for each patient before completing their charts, so I have exposure to all the different codes and what works and doesn’t for each diagnosis and when to pull in working diagnoses and new dx, and what to charge for on visit coding, etc., as far as new patients and established patients and time spent on care, etc. and what you can charge based on the number of systems evaluated, etc. Since I am familiar with this system from my FT job as an ED RN at LMH, this system is familiar to me. I also used this same system for documenting two other semesters of clinical rotations, only the templates were different as far as the chief complaint, but the way you document is the same. I would say I was at an advantage over other students who have not had exposure to this system, and it is not stressful for me to document in this format. Documenting using professional terminology is something I consistently try to do. It has been extremely helpful to have a computerized charting/documentation system to facilitate learning medically appropriate terminology. Overall, I believe I demonstrate meeting this outcome and am able to meet expectations with minimal support from my preceptor at HCA. The PANDA office uses computerized documentation, but a different program. The concept of selecting a template is the same, and it also allows you to select from common CPT codes based on the template that you choose, but also allows you to select a different one if you desire. I am not documenting in the system at PANDA, as I do not have my own login, and the system only allows one person to be in a particular patients chart at one time, and it is difficult enough to have the provider and the tech trying to enter information in the patients chart without being in there at the same time, so we made the decision that I would present the patient to my preceptor and she will enter the info in the system while I look over her shoulder! I think that giving a quick verbal pt presentation is also helpful by forcing more efficiency and practice with pt presenting. Either system allows you to enter modifiers as necessary. Also, it’s important to remember that in October 2013 ICD 10 is going to come out and replace ICD9 and any memorization we have done, so it’s good we are getting help from the computers and EMARs!10/24/12- I continue to demonstrate meeting this outcome by documenting using professional terminology, format and technology in my clinical settings with minimal support from my preceptors. Since my last submission, I have continued to use the computerized documentation system with more efficiency in proper documentation of terminology, format and technology. I required less assistance from my preceptor with E/M, ICD9 codes and CPT coding. It continues to be extremely helpful to have a computerized charting/documentation system to facilitate learning medically appropriate terminology. My continued goal is to improve in efficiency.11/26/12- -To document using professional terminology, format and technology means adapting to whatever system is used by the clinical site, and applying knowledge of terminology to descriptively describe and document conditions and symptoms. The format is generally dictated by the documentation system used, whether it be an electronic system or a paper form. At HCA, we use Cerner, which is what I am used to documenting with in my current position, so I find it user friendly, and easy to navigate for the most part. This is a system I feel comfortable with, so it allows me to focus on other aspects of documenting I continue to demonstrate meeting this outcome by documenting using professional terminology, format and technology in my clinical settings with minimal support from my preceptors. It continues to be extremely helpful to have a computerized charting/documentation system to facilitate learning medically appropriate terminology. I use an ICD-9 Consult app occasionally as well. I continue to improve in efficiency as well which was my previous goal. Overall, I believe I demonstrated significant improvement in meeting this outcome and was able to meet expectations with minimal support from my preceptor by the end of the practicum experience. ______________________________________________________________________________14. Initiate referrals by collaborating and consulting with □ □ □ □ X Xmembers of the health care team10/24/12- I have had several opportunities to collaborate and consult with other members of the health care team. Patients are often referred to other providers due to specialized care or limitations of services we are unable to provide in the local pediatric or safety net clinic settings. The challenges with working in the local pediatric setting are that there are not any pediatric specialists in Lawrence, except for a pediatric ophthalmologist. However, it is definitely a strength to have Children’s Mercy Hospital located in Kansas City, where there are multiple pediatric specialties at our fingertips that are just minutes, not hours away. Several recent examples demonstrate properly collaborating and consulting with specialists for the pediatric population. I recently cared for a 3 y.o. female patient who was brought in by her mother for insomnia. The patient’s mother reported she was only sleeping 1-2 hours at a time at night, was not napping, and was not surprisingly, cranky! After multiple possibilities and a lengthy discussion with the parent and the primary provider, a referral was made to Children’s Mercy sleep clinic for a sleep study. At the time of this entry, the patient had not yet been to CMH for her evaluation. Another example was a 2 y.o. male patient whom had developed a limp and an externally rotated right foot about 2 weeks prior to exam date. There was no trauma or injury noted and the patient did not appear to be in any pain; after appropriate labs and x-rays were obtained, with normal findings, a referral was made to CMH orthopedic specialists for evaluation. Another referral to CMH was a 5 y.o. female patient with a chronically ruptured TM; the patient was frequently dizzy and continued to have OM. The patient was referred to CMH ear, nose and throat specialists, where she subsequently underwent a successful tympanoplasty and is recovering as expected. Another example of collaborating with the specialists at CMH was a 5 y.o. female pt. who had a hx of CP and had a feeding tube and was having difficulty with feedings. The patient had been having increasing episodes of vomiting after CMH nutrition services had increased her tube feedings due to malnutrition issues. The patient was with a new foster mother who was concerned, so she was brought to the clinic for evaluation. Adjustments were made to her tube feedings in our clinic, so as to hopefully decrease the amount of vomiting episodes. We collaborated care with CMH nutrition services and scheduled a more frequent follow-up for the patient and her new foster mother – all parties involved were satisfied with the plan of care. This is another example of collaborating and referring when necessary. At HealthCare Access (HCA), we regularly collaborate with local specialists and often initiate referrals for our patients. There is a strong volunteer base of physicians and other providers that serve HCA. Every Monday there is a neurologist on site who sees patients we refer for headaches or other neuro issues, including nerve conduction testing. I recently had a 42 y.o. male patient with cervical radiculopathy that was not improving with physical therapy and Neurontin, so I referred him to see the neurologist, who did nerve conduction testing. We have a gynecologist who comes to the clinic a couple times a month and does colposcopies and sees patients with dysmenorrhea and other complicated gyn issues. I recently referred a 48 y.o. male to the general surgeon for an inguinal hernia repair consult. He subsequently had the hernia repair and is recovering as expected. These are just a few examples of collaborating and consulting with other health care providers to provide optimal care for patients. Overall, throughout this rotation, I feel I know when to refer and consult with other providers, and do not hesitate to do so when necessary. I have been in enough different areas at this point, combined with my professional experience, to feel confident in recognizing the need to refer and consult as needed. I will continue to work on this competency as opportunities arise in future clinical rotations and in practice.11/26/12- - Collaboration and consultation with other members of the health care team is key to the process of initiating referrals, and is necessary for the sustainability of advanced nursing practice. It is important to establish collaborative relationships in practice, and to utilize the skills and specialized knowledge of other professionals as well as the knowledge and skill of the support staff to arrange referrals and work out the details. I continue to have opportunities to collaborate and consult with other members of the health care team. Patients continue to be referred to other providers due to specialized care or limitations of services we are unable to provide in the local pediatric or safety net clinic settings. There are several examples that demonstrate competency for this outcome. For example, I had an 18 y.o. female patient who presented with cc of unintentional weight loss, nausea, poor appetite and abd pain; labs, ua normal. The mother was concerned about anorexia or bulimia. After a normal PE and detailed discussion about social history and sexual history, and pt reported not ever having been sexually active, not concerned about peer pressure and appearing to have realistic and “normal” social life without added peer pressures, I consulted with our social worker to visit with the patient to see if she could find something I was missing. The patient was not actively vomiting, but had continued nausea, and poor appetite. The social worker visited with the patient immediately in our clinic with negative findings and no need to see the patient again, unless desired. I subsequently had the pt follow-up with GI, and ordered some x-rays to rule out constipation or bowel obstruction first. This was the patient’s second visit in a week, having seen one of our volunteer physicians the week before. Another example is that I have worked with members of the health care team on the initiation of referrals for physical therapy services, and have had multiple opportunities to recommend this as an option for patients with low back pain. Additionally, on a daily basis patients are referred to the local health department for flu vaccination administration. By being a provider in Lawrence and already working in this area, I feel I have demonstrated skills to master this competency. If I choose a position outside of this area, I will need to become familiar with the network of health care services, providers, and community resources available to me as a provider and my patients as consumers. As I begin my career in advanced nursing practice, I will collaborate with other members, and do my best to provide comprehensive and coordinated services. As previously stated, overall throughout this and other clinical rotations, I feel I know when to refer and consult with other providers, and do not hesitate to do so when necessary. I have been in enough different areas at this point, combined with my professional experience, to feel confident in recognizing the need to refer and consult as needed. I will continue to work on this competency as opportunities arise in practice.__________________________________________________________________________15. Incorporate access, cost, efficacy and quality when □ □ □ □ □ X Xmaking care decisions10/24/12– I do my best on a daily basis not to order unnecessary tests on any patients. Prescriptions are written based primarily on EBP guidelines, and then based on insurance or ability to pay for certain RX, or they might be given a sample of a med, if it is comparable to what I am going to write the RX for. I do not feel like efficacy or quality is compromised in providing care for any patient in the pediatric or safety net clinic settings. Access is an issue for HCA patients who do not have insurance or funds for self-pay referrals – many providers in town will see a HCA patient free of charge for 1 visit, but the patient may be required to set up a payment plan for subsequent visits and for surgeries, if necessary. We collaborate with LMH for surgeries, and they write off the cost of anesthesia and the OR, but the patient is responsible for helping pay the surgeon. Options are always discussed with the patient in all circumstances so they are a direct participant in their care. At the pediatric office, they treat patients of all funding types, including Medicaid and self-pay patients, in addition to those with insurance. They do require that self-pay patients set up a payment plan of some sort. Once a patient was in the clinic, I do not believe efficacy and quality were compromised in any manner. Examples of incorporating this competency include seeing the following patients: I treated a 47 y.o. patient dx with with a peritonsillar abscess at HCA; utilized access for free referral to ENT doctor, who patient saw on same day, for drainage of peritonsillar abscess –Not only demonstrates effective referral and collaboration, but demonstrates proper use of community resources and was able to provide what was best for the patient and considered financial barriers to care in making appropriate referrals. Access, cost, efficacy and quality are always and will always be considered when making care decisions. The key is to make the best decision for the patient based on the circumstances and setting. 11/26/12 - The incorporation of access, cost, efficacy, and quality applies to the decision-making process on topics ranging from decisions about what medications to prescribe, to decisions about how to best provide patient education. Access to certain services is often a challenge when practicing in a safety net clinic and with a large Medicaid population in the pediatric office setting. Examples from this practicum that best illustrate my ability to perform this competency include not ordering unnecessary x-rays for complaints of low back pain. LBP is usually musculoskeletal in nature, especially if PE findings are consistent with MS pain and without major trauma or neuro changes. LBP can be further evaluated after initial treatment with rest, ice, OTC anti-inflammatories, and back exercises or PT if indicated. Maybe an occasional muscle relaxer is added. Another example is seeing pediatric patients present with a few days of diarrhea. The peds office usually doessn’t order stool studies unless the diarrhea has continued for more than 5-7 days, as it just isn’t cost effective and is usually not indicated. Of course exceptions occur and are considered on a case by case basis. Following EBP guidelines also assists me in determining what to order and the plan of care. Cost of care and patient responsibility for their own care are important considerations as well. The key remains being able to make the best decision for the patient based on the circumstances and setting. In addition to keeping track of the current generic and $4 list, reading journals and professional updates, and questioning pharmaceutical representatives will also be a priority. I will continue to use websites like to help my patients get the best price on RX meds, and will refer to various sources for information about the efficacy and quality of services, including professional journals and articles in current publications. ______________________________________________________________________________16. Perform care in a timely manner □ □ □ □ X X□10/24/12- Including documentation, it takes me 30 minutes on average to see and document on a patient; some acute urgent care type of patients are faster of course. I still believe I can and should be more efficient; however, my preceptors have all reported that “speed will come with time”. Maybe I am being too hard on myself, but my goal is to cut about 5-10 minutes off time in room just to get more efficient, but with keeping in mind to continue to do a thorough exam and to not cut corners or forget pertinent information. In the pediatric setting, when seeing a patient for a “sick” visit, I can often be in and out of a room in 5-10 minutes, depending on the patients’ chief complaint. In the HCA clinic, the patients are scheduled for 15 minute visits, and I often find it difficult to see patients in a timely manner, especially if they have multiple complaints. I am often reassured by my preceptors however, that “clinical confidence comes with time”. I continue to feel that it is important to provide good, thorough care, regardless of time spent with patients. My time management has also been potentiated by my desire to practice more independently- we are all looking for jobs when we finish school, and those preceptors/employers will have the chance to choose employees who they may have had experience with and those they feel can be efficient and make $$ for their practices. I plan to continue to improve my SOAP reports, and at this point I still feel it should take a little more time to assess and treat patients to ensure I am doing it correctly, without appearing rushed or like I’m not listening, all the while being thorough and accurate. As time has passed since the beginning of this clinical, I can say that I think I’ve improved greatly, and have cut about 5 minutes off the time in the room and time spent documenting, while continuing to be thorough. So, while I feel like I should be quicker, I also realize I am trying to keep up with providers who have been practicing 10-15 years. I also feel like I don’t want the patient’s to feel rushed. As I continue this final semester, I realize there’s still room for improvement, and feel that efficiency will improve with each passing day. Further practice and experience in the clinical setting will help me to refine my skills and increase my proficiency which will result in a timely care delivery from start to finish on a consistent basis. I will also continue to utilize reference materials such as my text books, Epocrates, and Stanford guide to antibiotics to increase my knowledge base that will also result in increased efficiency.11/26/12- Performing care in a timely manner means doing things on a daily basis to be timely with patient flow, and having a system in place to respond to patient questions/requests, document, and follow-up on issues in a timely fashion. At HCA, my preceptor has 13+ patients scheduled before lunch, and probably 6-8 after lunch, and occasionally has walk-in or add-on patients. At the beginning of this rotation I often felt behind, because I struggled with what issues and how many of them to address at each visit with this population. By the end of this rotation I was better able to organize my time and prioritize complaints better. My documentation improved and was more efficient. I was able to see more patients, with less wait time. I tried to see all the patients, with my preceptor seeing some if we started to get behind. My priority was in providing accurate and thorough care, and still is; I am just able to perform care in a timelier manner now. As I start my NP career, I plan to develop my own strategy for documentation and keeping up with patient flow based on my experiences and expectations of a new employer._____________________________________________________________________________17. Maintain confidentiality and privacy □ □ □ □ □ XX10/24/12- Patients are discussed in the office setting and privacy and confidentiality is maintained at all times. I always adhere to the WU policies, the MSN student handbook and “Student responsibilities” as outlined in the WU SON preceptor handbook. I also adhere to the clinical agency policies and procedures including HIPAA. Additionally, I continue to be conscientious in discussing patient information with my preceptor in a confidential manner and location. I have consistently maintained privacy and confidentiality of patients cared for in this practicum without guidance from my preceptors. Meeting this outcome is a priority in every health care environment and interaction. My preceptors and office staff would also attest to this matter without reservation. As a provider, this will continue to be a priority in the care I give my patients.11/26/12- Maintaining confidentiality and privacy means having respect for what is communicated by patients, treating information as if it is entrusted to us, and shared in the confidence that it would not be divulged to others unnecessarily. I do not find this to be a challenging competency, and am able to do this consistently for all patients by complying to the HIPPA regulations, and maintaining personal values. In addition to what was discussed above, I continue to protect the security of electronic information by logging out of electronic devices when not in use, and discuss patients with my preceptor in a discreet manner. Meeting this outcome is a priority in every health care environment and interaction. My preceptors and office staff would also attest to this matter without reservation. As a provider, this will continue to be a priority in the care I give my patients.______________________________________________________________________________18.Demonstrate professional behavior □ □ □ □ □ XX10/24/12- I am consistently on-time, dressed professionally, courteous to patients, family, staff and preceptors. I am consistently prepared, and conduct myself in an appropriate, professional manner and adhere to the dress code as expected and addressed in the WU SON student handbook and per facility guidelines. I have carried this into my personal life as well, even more so than in the past. For example, if I am out with friends, I am even more conscientious of my behavior, as there might be people around who are current or potential future patients, and if I am recognized, I want to be seen positively and professionally. Not that I get out much, but when out with friends or family I really thought about this – perception is everything! 11/26/12 – In addition to continuing the above stated practices, I continue to come to clinical promptly and appropriately dressed. I wear my lab coat with Washburn ID badge prominent. I am always polite, courteous and well-spoken, with the intent of always being professionally kind, courteous and respectful, no matter what the situation. I have remained calm under all circumstances and was never reactionary. I follow the ANA Code of Ethics in my practice. The medical profession demands providers are responsible, accountable, motivated, and self-directed. This includes a responsibility to maintain a sense of integrity, trust, safety, competence, and to continue to progress in personal and professional growth. I am confident that my preceptor and office staff at my clinical site would attest to this matter without reservation. 19. Demonstrate emotional resilience and stability □ □ □ □ □ Xxadaptability, flexibility and tolerance of ambiguityI believe I am always polite, courteous and well-spoken, with the intent of always being professionally kind, courteous and respectful, no matter what the situation. I have remained calm under all circumstances and am never reactionary. I follow the ANA Code of Ethics in my practice. The medical profession demands providers are responsible, accountable, motivated, and self-directed. This includes a responsibility to maintain a sense of integrity, trust, safety, competence, and to continue to progress in personal and professional growth. I am confident that my preceptor and office staff at my clinical site would attest to this matter without reservation.11/26/12 – Emotional resilience and stability is demonstrated by a person's ability to remain emotionally balanced and stable through adversity, and despite being faced with situations and tested with decisions that challenge and stretch us emotionally. Being adaptable, flexible, and tolerant of ambiguity requires a person to not be rigid or set in a particular way, but to be open to the variability of human interactions, and to be tolerant of the unknown. In addition to the above comments, I believe I demonstrate emotional stability by maintaining emotional balance under stressful circumstances. I minimize emotional reactions and try not to over-react to the small stuff. I try to maintain a neutral presence. I had a 28 y.o. male patient who continued to ask for an abx for treatment of dysuria because he thought it helped before. He had a negative UA, negative STI screening the week before and several negative results prior to that. He insisted on an abx, even though I explained the rational that it was not indicated. I offered a consult with the urologist, he stated “What is he going to do for me that you cannot?”; I explained that he was a specialist in this area and was my only recommendation at the time considering all the recent negative test results- he was only asking for abx, not pain meds – I should have given it to him, right?! When the nurse tried to assist the patient in setting up the referral, the patient mentioned that he lived in KC, not in Lawrence, so it was difficult to schedule. The patient was informed that he did not meet criteria for receiving services in our office since he was no longer a resident of Douglas County; the patient then changed his story to say he lived with his brother in Lawrence. He ended up leaving, agitated and disgruntled, stating “I’ve been here 5 times and you guys haven’t done anything for me anyway”; the patient was subsequently sent a “termination letter” by my preceptor. In that experience, I remained calm and matter of fact, emotionally resilient, stable and tolerant. My continued experiences, personality, and world view will continue to contribute to my ability to achieve emotional resilience and stability, adaptability, flexibility, and tolerance of ambiguity. Well-validated reference materials will continue to support my ability to be tolerant of ambiguity. ______________________________________________________________________________20. Employ effective communication methods with patients, □ □ □ □ □ X Xfamilies, preceptor, and staff10/24/12- I introduce myself to each patient and their family upon entering the room, sit down next to them, discuss their CC and do their evaluation and exam, all while maintaining respect for them and their time. I always ask “Are there any other issues or questions I can answer for you today?” before I leave the room. I communicate well with my preceptor and the staff nurse and feel we have a good working relationship. I am appreciative and thankful of their time and patience, verbalize such and will continue to do so. My preceptors and I have a good working relationship and they knows they can give me feedback about anything at any time and I will be receptive, as I want to learn and do well and become a great NP. My preceptors have verbalized they feel like it is their role to be good role models and teachers and know that individuals who will someday be working beside them have been properly trained. Additionally, I feel patients, families, staff and my preceptor have been very receptive and gracious to me. I continue to employ effective communication methods, and know that active listening, paired with summarizing and clarifying is the best method. I don’t want patients to feel I am not listening to their concerns. If I want to speak, I often remind myself to take a deep breath first, to make sure I am thinking before speaking, and that the patient doesn’t have anything further to add at the time – I don’t want to interrupt. Effective communication requires a variety of tools and techniques in an effort to gain trust, respect and participation with patients, families, staff, faculty and preceptors. I share my personal experiences when appropriate – it’s not about me and I don’t want patients to feel I have a similar experience for every one of theirs. Gaining knowledge and knowing the time and place to share personal experiences will improve with time. It would be appropriate to share my personal experiences if I see an opportunity for education and I might be able to relate my personal experience to put a patient or family member at ease.11/26/12 – To employ effective communication methods with patients, families, preceptor and staff generally means using a variety of methods of communication, depending on the situation and the needs of the individual(s) with whom you are attempting to communicate. I have more than 12 years of nursing experience, which has provided me the opportunity to practice this competency, and has been a strength for me as I learn new and advanced methods of communicating with patients, families and staff. In addition, I continue to effectively and openly communicate with my patients, their families, my preceptor and staff. Utilizing lay terminology is a good example when discussing diagnoses, treatment and follow-up with patients. In the future, I will study issues contributing the health literacy of my patients and use the information to ensure that communication methods are effective. I will make efforts to follow up with patients making sure they are heard. References and clinical guides that help me in being able to achieve this competency include the patient education materials that I use to meaningfully communicate key teaching points with patients. ______________________________________________________________________________21. Assess the agency for cultural competence □ □ □ □ □ XX10/24/12 Cultural competence refers to an ability to interact effectively with people of different cultures, particularly in the context of organizations whose employees work with persons from different cultural/ethnic backgrounds. Cultural competence comprises four components: 1) awareness, 2) attitude, 3) knowledge, and 4) skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures (Wikipedia, 2012). The healthcare profession was the first to promote cultural competence, and not surprisingly so. A poor diagnosis due to lack of cultural understanding can have fatal consequences, especially in medical service delivery. Whether it is emphasizing the knowledge and skills needed to interact with people of different cultures, or focus on attitudes towards others of culturally diverse backgrounds, it is difficult to measure cultural competence. On a daily basis, I strive to improve cultural competence and effectiveness. At the pediatrics office, Dr. Vangarsse sees most of the Spanish speaking patients because she is the only provider in the office that speaks Spanish. She has commented on how that helps her with her Spanish fluency, and also helps with continuity of care. She has commented, however, that she doesn’t feel it is fair that she sees all the Spanish speaking patients and her partners don’t see very many, just because of her ability to speak Spanish. The pediatric office does have an interpreter there as part of their staff on a daily basis – she has another role there as well, but serves as the interpreter when needed. HCA also tries to schedule their Spanish speaking patients on the 2-3+ days of the week that they have an interpreter on site. Another example of a situation where cultural competence was demonstrated is in the care of a 41 y.o. female patient, whom, after presenting with a chronic, worsening cough and weight loss, and after obtaining a chest xray, which then led to a chest CT and newly dx metastatic lung cancer. The patient is a non-English speaking patient, was accompanied by her English speaking family members; the patient is uninsured. Arrangements were made for prompt follow-up and consultation with a pulmonologist and oncologist. The patient is currently undergoing chemotherapy and radiation for stage 4 metastatic lung ca. It’s easy to see how seamless this consultation and referral has been, but it could have easily been passed off as something insignificant like a chronic cough or “smoker’s cough” or treated with OTC meds, or even an abx. It could have been entirely ignored if a culturally insensitive person were caring for this patient. If the patient didn’t present with family, or an interpreter wasn’t utilized, or if the patient was treated poorly because she didn’t speak English…the situation could have turned out much different. It’s sometimes difficult to describe how I feel culturally competent. I believe it has been a learned behavior over time. I have consciously, over time, become more aware and have developed my own cultural worldview, have developed my own attitude towards cultural differences, become knowledgeable of different cultural practices and worldviews, and have developed and practice cross-cultural skills over time. I have learned a great deal from being a nurse and being in culturally diverse situations frequently over the years. As a provider, I continuously strive to treat all patients equally at all times and to be sensitive to their cultural differences and needs and will continue to do so. I try to listen to my patients and follow their cues. I will continue to be sensitive to other cultures and to not answer questions for the patient, but give them choices and let them have the opportunity to answer for themselves. This is an area that can always be improved upon. I don’t want to be the provider whose patients feel like “they never listen to me or hear what I am saying”. Being sensitive to patients with physical disabilities is also demonstrated on multiple occasions by providing assistance in applying for disability, approving handicapped car tags, and recommending and approving adjunctive devices such as walkers, wheelchairs, canes, crutches, etc. to assist with mobility needs. Just last week a 5 y.o. pediatric patient with CP needed a new wheelchair – we were able assist the parent in writing a rx for one, and providing proper documentation and a supplier to help expedite this request. I plan to continue to develop an understanding of the belief systems and preferences of the diverse populations served in our area, and know it will continue to be helpful in providing effective care for all patients across the lifespan.11/26/12- Cultural competence refers to an ability to interact effectively with people of different cultures, particularly in the context of organizations whose employees work with persons from different cultural/ethnic backgrounds. Cultural competence comprises four components: 1) awareness, 2) attitude, 3) knowledge, and 4) skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures (Wikipedia, 2012). I feel this clinical has given me opportunities to be exposed to a variety of generational, cultural, spiritual, financial and ethical cultures, to name a few. There are multiple Spanish speaking patients who come to HCA and the peds office – we usually have a translator scheduled at HCA and try to schedule those patients on the days that the translator is there, although that is not always possible. Sensitivity to the shifting demographics of our patient populations is crucial and ongoing. I plan to continue to develop an understanding of the belief systems and preferences of the diverse populations served in our area, and know it will continue to be helpful in providing effective care for all patients across the lifespan. I take cultural competence seriously and feel being knowledgeable and aware can only increase patient satisfaction over time. ____________________________________________________________________________22. Communicate practice knowledge effectively both □ □ □ □ X Xorally and in writing10/24/12- I am continually improving on my verbal SOAP reports, and improving on my documentation skills as well in the patient’s paper and electronic record. I improve with each patient and each day, and my preceptors also feel I am making great progress in orally presenting patient findings and in writing. I will continue to work on this area, as each facility has a different method for patient documentation and preference for presenting patients from a student and preceptor perspective. The Pediatrics office uses an electronic documentation and ordering system, but it is different than the Cerner computerized Powerchart documentation used at HealthCare Access. I am open to new ideas and ways to improve based on preceptor input and suggestions. I’ve had a lot of practice in communicating practice knowledge in written form after previous reflection papers, written and oral case study presentations and a lengthy outcomes evaluation. Elogs for every patient seen was also completed.11/26/12- The above comments still apply. Additionally, being able to communicate practice knowledge effectively means being able to explain things in common terms, and being able to discuss practice issues intellectually, using professional medical terms, as well as being able to successfully write an organized assessment and plan. I am certain I will be more effective as I gain knowledge and experience as a provider of care. Listening to the ways that other health care professionals explain things is another good way to improve in this competency. I plan to continue to use the 'teach-back' method with patients frequently to ensure that I have communicated knowledge effectively, and that patients truly understand what is being said. _____________________________________________________________________________23. Integrate best available evidence to continuously □ □ □ □ X Ximprove quality clinical practice10/24/12- I strive to use the best available evidence to continuously improve my quality of clinical practice. I receive “DocAlert message” notifications from Epocrates which I consistently read. I also receive email updates from Medscape Daily News, Medscape News Alert, and the NCCN. I reference Ferri’s clinical advisor and Epocrates daily. I also utilize reference books available in my preceptors’ office; I reference online sites like Up to Date, and use my Tarascon and Sanford guides regularly as needed. I utilized the AHA, CDC, and ACC, ACOG, AHRQ and other guidelines and websites as appropriate. My preceptors are supportive and encourage looking up information on a regular basis to stay up to date and to give patients the best available care based on current practice and guidelines. Reassuringly, each preceptor has mentioned to never be afraid to look up information and praised my abilities to utilize my iPhone or other readily available resources when I didn’t know the information off the top of my head. We look up information together, often times seeing who could find the information the quickest, using different resources. The feedback from my preceptors, both verbally on an ongoing basis, and in their written evaluations, is reflective of my demonstrating growth in the quality of my clinical practice. Other staff members in the clinics were also aware of my desire to improve my quality of care and my continuous desire to learn and have enthusiasm.11/26/12- Integration of best available evidence to continuously improve quality clinical practice means applying the best available knowledge from sources that are reputable and up to date to continually improve clinical practice. As stated above, I strive to use the best available evidence to continuously improve my quality of clinical practice and will continue to do so. I plan to continue to utilize the above resources listed, as well as any additional resources that may be recommended by my colleagues. For example, I would not have known about the website if it weren’t for my preceptors – this type of knowledge and integration demonstrates use of best quality practice and the desire to improve. It’s also going the extra mile and striving for excellence that helps providers achieve successful and long term patient and personal satisfaction. I have been reassured by positive feedback from my preceptors and others I work with that I demonstrate the desire to improve the quality of my care by constantly reviewing best available evidence. An example of demonstrating competency in this area is having a patient with a suspected sinus infection that desired a “Z-pack”; the patient was not too acutely ill, although her symptoms had been going on for more than 7-10 days. In providing prudent and evidence based care, I prescribed Amoxicillin. I explained EBP to the patient and the rationale for RX Amoxicillin – plus it was much cheaper than azithromycin, and the patient was uninsured and not able to pay their $10 copay that day – so I felt it was a win-win situation The patient was hesitant at first, stating “amoxicillin doesn’t usually work for me”, but the patient hadn’t had it in more than 3 years. My preceptor was considering a z-pack for the patient when we were discussing treatment plans, but I mentioned that I couldn’t find rationale in RX a zpack for this particular patient. My preceptor was receptive and she agreed to my plan to RX Amoxicillin. The patient agreed to try it, and subsequently improved. In the future, I will work continuously to integrate best available evidence in to my practice, and will be vigilant about ways to continuously improve. References and clinical guidelines that have helped me achieve this competency include clinical guidelines from the National Clearinghouse Guidelines, and the use of UpToDate database, and other current sources.______________________________________________________________________________24. Analyze agency educational tools □ □ □ □ X X10/24/12- In both the pediatric and HCA setting, each facility has policies and protocols that are followed, and are available for review by employees as needed to facilitate being up to date on education. I would say that besides using the educational tools I brought to clinical at the urgent care site, including my own reference materials, there were educational tools available to patients and caregivers, including vaccine recommendations, community class offerings where flyers are distributed to patients or their families – for example – a pharmaceutical company was having a community meeting for diabetic patients and was free to the public – we handed out information of the seminar to all our diabetic patients at HCA, and hung flyers in each room. Notifications are posted everywhere, including the bathrooms, at the pediatric officer, regarding the influenza vaccine and who should receive it, etc. There were also multiple handouts on multiple topics in every patient room and in the lobby of the offices. These were readily available to patients at all times, and were referred to and handed out when appropriate. I do not hesitate, however, to pull out my phone and share educational information with patients or caregivers/preceptors, if I feel it is in the best interest of the patient’s health. I will continue to do that as I see necessary so that the patient gets the best information available that helps them understand the plan of care. 11/26/12- To analyze agency educational tools means to examine in detail the elements, and usefulness of the tools used to educate patients on a variety of topics. I provide effective, individualized health care to my patients and caregivers when assessing their needs. This includes verbal, written and demonstrated education when necessary. In addition to the above resources, an example of meeting this competency include providing common educational tools given to patients on back and neck exercises for LBP diagnosis and cervical strain, common complaints in the FP setting. The website is another good example of an agency tool that is analyzed. HCA has social workers and case managers and Spanish interpreters on staff – excellent agency tools that are utilized on a daily basis and are great assets to HCA. HCA also has a prescription assistance program and a staff member dedicated to facilitating managing this program. HCA also has computer generated discharge education that is part of their depart summary. Each patient is given a handout of discharge instructions that are computer generated; include diagnosis with a description, plan including current and new meds prescribed, follow-up and referral information, with appropriate phone numbers. These are also available in Spanish. References used to provide educational tools include the use of the tools built into the Cerner PowerChart system (as described above). A couple of times, I have supplemented with the educational materials found in the UpToDate database, including once for a patient who was interested in receiving the shingles vaccine. In the future, I will work to maximize the available resources, and will always strive to provide patients with tools for education that are based on best available evidence, and are presented in the most useful and effective way known. _____________________________________________________________________________25. Evaluate the outcomes of coaching patients □ □ □ □ X X10/24/12- Coaching is the guidance provided to the patient in an effort to assist them in improving their health status. Coaching has been integrated in my care during this practicum by encouraging smoking cessation, dietary changes for patients who are diabetic, low sodium intake for patients with hypertension, high fiber and low fat diet and implementing regular exercise for those patients with increased cardiovascular risk factors, to name a few. It is also important to emphasize what patients are doing effectively to improve their overall health, and to give feedback with small incremental changes that the patient can handle – make one change at a time so the patient and caregiver can manage and not be overwhelmed. Praising patients for achieving goals and continuous encouragement is regularly incorporated in the ongoing care of my patients. It remains essential in establishing trusting relationships and providing continuity of care to focus on successes and help patients establish and meet individual and team goals.11/26/12- Coaching is the guidance provided to the patient in an effort to assist them in improving their health status. The above submission still applies to coaching examples. The challenge of evaluating coaching is that it is difficult to evaluate the long-term outcomes of coaching patients without the opportunity to be in the clinic for longer periods of time and not being able to see patients for follow-up sometimes. One example of coaching a patient was a man who wasn’t going to get the flu vaccine until I educated him on exactly what it was and how it worked. He then decided to get the flu vaccine – it was just a matter of taking the time to properly educate and “coach” the patient- the outcome was evaluated immediately, as he received the flu vaccine – instant gratification?! Seeing patients for follow-up of HTN with improvement since last visit, and DM with tighter control are also examples of evaluating coaching. I continue to educate on disease processes, risks and benefits of medications and involve patients in their own “self-coaching” for improved outcomes. Referrals are made for psychiatric and behavioral support, including to the Bert Nash Mental Health counseling center. Often times the office staff is utilized for follow-up and evaluation of patient outcomes when they are asked to make follow-up phone calls. In the future, I hope to become a better and more effective coach, using skills to empower and enable patients. This will be evident with experience and opportunity. Evaluation of outcomes can be done in a variety of ways. References include articles and manuscripts about techniques such as motivational interviewing, goal setting/action planning, and telephone interventions._________________________________________________________________________26. Integrate appropriate technology for knowledge □ □ □ □ X X management to improve health care10/24/12- My ability to define patient problems and integrate appropriate technology in a systematic approach while obtaining histories and performing comprehensive and focused physical exams based on patient presentations demonstrates knowledge management in improving health care for all patients across the lifespan. I am constantly improving my ability to identify what information is needed, to understand how information is organized, to identify the best sources of information for a given need, to locate those sources, to evaluate the sources critically, and to share that information. The utilization of electronic medical records is a great example. I can see my current patient status, past histories and exams and visits to other providers and systems who utilize the same technology. I am improving my ability to research for the best evidence-based practice. Even when I do have experience with a disease, it is still imperative to have the latest research available. Continuing to utilize the most up to date resources will facilitate learning and will continue to demonstrate how to properly and comprehensively integrate appropriate technology for knowledge management while striving to improve health care for all patients.11/26/12- To integrate appropriate technology for knowledge management means to use the technology available to help with the organization and transfer of knowledge. When done effectively, health care should be improved. The above statements continue to apply to this submission. This competency is also demonstrated by examples of being able to navigate the electronic chart, and integrate fax, phone, print, and copy capabilities in this clinical setting, to better manage patient information, and improve the efficiency of care. The appropriate use of available technology for knowledge management promotes continuity of care, and in turn, contributes to the improvement of health care. As I begin my NP practice, I will continue to use technology appropriately, integrating tools that will help me with organization, management, and transfer of knowledge, all while remaining vigilant about protecting privacy and confidentiality, and taking the necessary precautions to protect personal health information. The use of a laptop during this clinical experience along with open access have been helpful in achieving this competency as well.______________________________________________________________________________27. Integrate ethical principles in decision making □ □ □ □ X X10/24/12- Respect for patient autonomy, beneficence and justice are key ethical principles in providing patient care and being a respected provider. I make concentrated efforts on an ongoing basis to integrate ethical principles in my decision making and I believe in utilizing the ANA Code of Ethics. I plan to continue this practice to the best of my abilities. For example, it is not my position to push my views or opinions on my patients, but to give them the information to make informed choices that best fit the needs of their health and overall well-being. I have to respect their choices and decisions – I can only guide them as I see appropriate based on my education and experience.11/26/12- In addition to the above submission, it is important to add that the integration of ethical principles in decision making means taking certain things into account when making decisions to ensure that the best decisions are made in support of patient well-being. A clear understanding of ethical principles and consistency in the application of principles is a strength when faced with making difficult decisions. First and foremost, there must be respect for human dignity in all decisions made. In the future, I will continue to integrate ethical principles in decision making. I will hold true to the concepts that I have certain responsibilities to myself, to patients and to society, and will seek ethical and legal guidance when needed. Concepts described by the American Nurses Association (ANA) Code of Ethics have been applicable to me as I worked to achieve this competency, including the ethical concept of respect for patient autonomy, the right to self-determination, the importance of interdisciplinary collaboration, and professional accountability. As I shape the future of my NP career, ethical principles will continue to be integrated into my decision making.______________________________________________________________________________28. Demonstrate respect, compassion and integrity □ □ □ □ □ XX10/24/12 - I always demonstrate respect, compassion, and integrity with my patients and coworkers. I do not feel there is any other way to practice. I also feel like my co-workers, preceptors and other staff, as well as patients would feel the same way about the way I practice, and I believe they would say so without reservation. Examples of respect include an introduction to the patient when entering the room, shaking hands when appropriate, sitting down by the patient and making good eye contact when appropriate, and knowing in which situations/cultures eye contact and hand shaking is not appropriate. Compassion might include a hug and is genuinely caring for patients and their families the way you want your own family to be cared for. Integrity is being honest and trustworthy and developing life ling relationships with patients, their families, as well as establishing trusting relationships with other providers and caregivers with whom I work with and around. As I continue my clinical practice, I will always consider the Golden Rule (“treat others the way you want to be treated”) when taking care of patients and when communicating with my co-workers, preceptors and other staff. 11/26/12- The demonstration of respect, compassion, and integrity means that these things are exhibited in every patient encounter and also in the interactions with colleagues. I continue to demonstrate respect, compassion and integrity with my patients and coworkers. This is my own personal standard of care. Examples of this in my current clinical settings include my ongoing respect for my preceptor and the other health care professionals with whom I have had contact, compassion for patients and families, regardless of their background, and always demonstrating integrity. Personal experiences and moral character are as much of a reference and guide for achieving this competency as any other. These principles will help guide my future practice as a Nurse Practitioner.State Board of Nursing RequirementKSBN Requirements for Nurse PractitionersMetNot Metor N/ACommentsDemonstrates advanced practice roleXDisplays ability to decide to order and/or perform diagnostic proceduresXAble to interpret diagnostic and assessment findingsXSelects and provides prescription of medications and other treatment modalities for clientsXSubmission #1 after 80 hours of practicumPlease review steps for CPT development – starting with a clear explanation of what the competency means so that examples are focused and show skill development and level of independence. In preparation for second submission please clarify these points. It is not clear what rating has been chosen for some competencies and they need to be in the 0 – 1- 2 – 3 -4 -5 increments for the scale. Faculty Signature__Bobbe Mansfield_________________________Date__10/2/12___________Submission #2 after 160 hours of practicumImproved clarity in defining and discussing required competencies. Examples are relevant. I can better see how you are thinking and acting as you progress into the final portion of your formal clinical education. You might strive for concise writing as you complete your CPT – you are at 27 pages now!Faculty Signature____Bobbe Mansfield___________________Date__11/1/12____________Final Submission after 225 hours of practicumStudent Signature____Trccy Hill______________________ Date__12/7/12__________Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade:November, 2011Revised August 2012 ................
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