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October 18, 2011Washburn UniversitySchool of NursingNU 602 Clinical Performance ToolStudent___Tracy Hill_____________________Semester___Fall 2011_____Agency__Karen Evans, DO; Mt. Oread Family Practice, Lawrence, KSInstructor_Dr. Shirley DinkelClinical 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 a 70% 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 donot 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 experiencesGradingThe Clinical Performance Tool is completed and submitted by the student at the completion of 80 clinical hours, 160 clinical hours, and all clinical hours for a total of three submissions. The first submission must address items 1-18, The second submission must address items 1-22. The final submission must address all competencies. 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: 0 1 2 3 4 51.Provide age appropriate health promotion, disease □ □ □ x x □prevention and health protection services. Influenza vaccine promotion, breast exams and PAP exams are just a few ways that I meet this expectation and will continue to promote vaccines, seatbelt use, contraception management and other screenings as appropriate2. Provide anticipatory guidance and health counseling □ □ □ □ x □(eg: lifestyle, tobacco/ETOH/ use, weight management,safety, immunizations)I regularly remind staff and encourage eligible patients to get influenza vaccines. I have even asked the nurse “How many flu vaccines are we going to give today?” I also encourage other “due” vaccines, such as tetanus, shingles, pneumonia, etc. I had a patient the week of 1012/11 that was inquiring about the shingles vaccine; it was age appropriate for her and she had several questions, so while we were discussing it, I went online to the manufacturers website and printed off a patient information fact sheet for her before she left to answer any other questions she might have before deciding whether or not to get it. We use computerized documentation in the exam rooms, so it was easy for me to do that while we were discussing it. I regularly offer smoking cessation information to those patients who smoke, if they are interested, and to those who expose their young ones to second hand smoke, emphasizing the long term effects of exposure to second hand smoke. I don’t shove it down their throat, but offer in a nice, educational manner. _______________________3. Identify etiologies, risk factors, underlying pathologic □ □ □ x □ □processes and epidemiology for medical conditions includinghypertension, lipid disorders, chronic and acute respiratory conditions, diabetes and thyroid disordersEach patient is asked about family history, it is documented and reviewed at each visit; personal social, medical and surgical histories are also obtained. With family hx of CAD, HTN, DM, hyperlipidemia, patients are screened at an earlier age for such disorders since they have + family hx – such as fasting blood glucose studies or fasting lipid profiles; close attention to ongoing BP readings. TSH and breast ca screenings such as mammograms or ultrasounds are closely followed and ordered at earlier ages in those patients with + family hx as well.Perform comprehensive health history and □ □ □ x x □physical examination to formulate basic differential diagnosesIn a recent meeting with my preceptor about my performance, she stated that I was “doing a great job with obtaining health histories, doing physical exams, documenting and explaining care to and educating patients about their diagnoses”. 5.Perform problem-focused health history and □ □ □ x □ □physical examination to formulate basic differential diagnosesSome examples of problem-focused health hx and physical exams with DiffDx. I have done include, but are not limited to: annual pelvic and PAP exams with Breast Exam for well-woman check-ups; ingrown toenail with removal; sough/wheezing/sob/- asthma exacerbation, bronchitis ,pneumonia. COPD; eye redness and pain – conjunctivitis, corneal abrasion, foreign body; sore throat – pharyngitis, allergic rhinitis, bronchitis; contraception management; diaper rash – candidiasis; runny nose, ear pain and cough – allergic rhinitis; My preceptor stated that I was doing a good job with differential diagnoses, and just needed to work on “finesse”, and needed to” tweak” diagnostic test selection based on common/likely DD and severity of illness/disease. 6.Participate in diagnostic reasoning in clinical decision □ □ □ x □ □making and development of a treatment planEach patient that I see is discussed with my preceptor. We participate together in diagnostic reasoning and clinical decision making and develop a treatment plan together. Usually, I see each patient individually, then present my patient to my preceptor, giving her a brief report/SOAP presentation, she will give her feedback and make any further recommendations or suggestions, then we go together to see the patient briefly and will discuss the plan of care with the patient based on our team approach to treatment. We have a dialogue between patients and at the end of the day when reviewing documentation on each patient about “what is good and what needs some work”; therefore, I have daily and up to date feedback on patient care, treatment plans and suggestions.7.Recommend screenings for common diagnoses of □ □ □ x □ □hypertension, lipid disorders, chronic respiratory conditions, diabetes and thyroid disordersOn an ongoing, daily basis, we screen new and established patients for HTN, DM, lipid disorders, asthma, COPD, and thyroid disorders. All patients have a complete set of VS on arrival, so BP is always included. New and established patients frequently do BP readings daily for 2 weeks and bring in results on a 2week follow-up – either when first dx with HTN, if changing meds, or starting meds; TSH levels are frequently checked on patients– we had a 39 year old female patient that was c/o hot flashes, hair loss, irritability, dry skin, fatigue, irregular menstrual cycles last 3-4 months; dx was Hashimoto’s after checking thyroid levels. After med changes for HTN and before initiating antihypertensive drug therapy, we monitor kidney function tests (BUN/Creatinine) and serum potassium levels. If patients are on lipid lowering agents, we monitor lipid levels every 6 months and check LFT’s prior to initiation of therapy; We also educate patients on fasting prior to labs for accuracy. There is a lab in the office, and before lab draws we ask patients when the last PO intake was so we can determine when to draw labs. DM patients usually bring in 2 weeks of fingerstick blood glucose levels prior to initiating therapy with either Metformin or before initiating insulins – most commonly seen initiation of a new glucose lowering agent is Levemir or Lantus; in the clinic I am working in we usually prescribe Levemir and start low at 10u qhs and see pt in 2 weeks. We have an established pt with hx of myeloma and are newly dx DM – initially started on Actos and Metformin; we see him every 2 weeks, have increased his dose of Actos and added Levemir and have changed his dose from 10u qhs, to 20u qhs, to 30u qhs and have seen incremental changes, but are moving slowly. Pt is adherent to therapy and is actively involved in improving his health. He had a visit where his blood sugars were in the low 300’s at home and a spot check in the office was in the low 200’s; so we had him go home and check his monitor and make sure he did the controls on it, and found his monitor to be 100 points different than ours, so we got him a new monitor. _____8.Recommend diagnostic strategies (i.e.: Holter monitor □ □ □ x □ □EKG, spirometry)______No opportunity for Holter or spirometry testing, but have had several patients need EKG’s; Had a new pt with new dx of murmur, did EKG in clinic; also had pt with new carotid bruit – did EKG; both patients were also scheduled for echocardiograms. Had a pt with hx of sickle cell anemia; had several trips to ED for chest pain– found murmur in clinic that had not previously been worked up, so ordered echocardiogram. ________________________________________________________________________9. Discuss evidence-based treatment information □ □ □ x □ □in patient careDiscussion had with newly dx diabetic patient included the following information: Lifestyle changes plus metformin are initial antihyperglycemic therapy for most DM2 patients. If HGBA1C is above individual goal, pharmacotherapy is generally recommended to reduce the risk of microvascular complications (nephropathy, retinopathy, and neuropathy).. The ADA recommends that metformin be started concurrently with nonpharmacologic therapy when HBGA1C is above goal, because of the difficulty in achieving and maintaining lifestyle change. Metformin is the only glucose-lowering therapy that has been shown to possibly reduce cardiovascular mortality in type 2 DM. 10. Recommend medications based on diagnoses, □ □ □ x □ □efficacy, safety, cost, and individual patient needs______In the practice that I am doing my practicum, patients with all forms of insurance are accepted, including Medicare, Medicaid, private pay, and commercial insurance. It is one of the few, if not the only practice in Lawrence that accepts Medicaid patients, so the “$4 list” is discussed frequently as cost of Rx’s is one of the primary concerns we hear from most patients. Samples of medications are also given when they are available and appropriate. 11. Perform medical and surgical procedures as appropriate □ □ □ x □ □Have had 2-3 opportunities to perform cryotherapy on a few actinic keratosis lesions; Have done about 6-8 PAP’s and breast exams; No opportunity yet for laceration repair. Have observed one punch biopsy; observed one toenail removal; Assisted with one KOH slide/wet prep; No opportunities yet for radiology interpretation or prenatal care.12.Evaluate patient response to treatment □ □ □ x x □Many of the patients seen in the clinic return for follow-up visits every 2 weeks, so I have had the opportunity to see many patients for follow-up on HTN, DM and med changes and how well they are working for the patient and what have BP measurements and blood glucose readings and do further changes or additions need to be made. 13.Document using professional terminology, □ □ □ x x □format and technology (i.e.: ICD9, E/M coding, CPT)______I am the first student that has worked with this preceptor that has attempted to use the computerized documentation system. It takes a little longer initially, but you have to select the right diagnosis ( a drop down menu pops up for your dx and you have to select the proper one”; E/M coding, 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. Dr. Evans has been helpful in explaining these criteria and in making suggestions and giving input in this area. It’s a real eye opener and will definitely help with future charting and selection of CPT and ICD-9/10 coding. I could say I started out pretty “green”, but now mostly I know what dx to choose and which templates to select based on the patients chief complaint. It gets better and more accurate daily. One of the benefits to using computerized documentation is it helps you find the right terminology and you select what you want with the option of adding additional notes or terms or free text writing, such as “consistent with yeast or candidiasis”, etc. ________________________________________________________________________14. Perform care in a timely manner □ □ □ x □ □______Including documentation, it takes me 30-45 minutes on average to see and document on a patient; some acute urgent care type of patients are faster of course. My preceptor and I have discussed the “Timely manner” issue, and where I feel like I should be quicker at times, she feels like each patient that I see is helpful to her. Also, she has stated “I don’t care how many patients you see, as long as you are providing good care and are thorough and are doing it right – speed will come with time”. My goal is to cut about 5-10 minutes off time in room just to get more efficient by the end of the semester, but with keeping in mind to continue to do a thorough exam and to not cut corners or forget pertinent information.15. Maintain confidentiality and privacy □ □ □ □ □ x______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.____________________16.Demonstrate professional behavior □ □ □ □ □ x______I am consistently on-time, dressed professionally, courteous to patients, family, staff and preceptor. 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._____________________17. Employ effective communication methods with patients, □ □ □ □ □ xfamilies, preceptor, staff, and faculty______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. Dr. Evans and I have a good working relationship and she knows she 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. She feels like it is her role to be a good role model and teacher and know that individuals who will someday be working beside her have been properly trained. 18. Provide culturally sensitive care to patients and families □ □ □ □ □ x______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. ________________________________________________________________________municate practice knowledge effectively □ □ □ □ □ □Both orally and in writing________________________20.Use best available evidence to continuously □ □ □ □ □ □improve quality of clinical practice______________________________21.Asses patient and caregiver educational needs to □ □ □ □ □ □provide effective, personalized health care____________________________________22.Coach the patient and caregiver for positive behavioral □ □ □ □ □ □change____________23.Demonstrate information literacy skills in complex □ □ □ □ □ □decision-making24.Integrate ethical principles in decision making □ □ □ □ □ □25.Demonstrate respect, compassion, and integrity □ □ □ □ □ □KSBN Requirements for Nurse PractitionersMetNot Metor N/ACommentsDemonstrates advanced practice roleDisplays ability to decide to order and/or perform diagnostic proceduresAble to interpret diagnostic and assessment findingsSelects and provides prescription of medications and other treatment modalities for clients?Submission #1 after 80 hours of practicumStudent Signature_____Tracy Hill____________Date___10/23/2011_________________Faculty Signature______________________________________Date____________________Submission #2 after 160 hours of practicumStudent Signature_____________________________________Date____________________Faculty Signature_____________________________________Date____________________Final SubmissionStudent Signature_____________________________________Date____________________Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade: ................
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