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Washburn UniversitySchool of NursingNU 607 Health Care Practicum II- Specialty (Adult) Clinical Performance Tool(Completed by Student and Faculty)Student____Tracy Hill___________________Semester___Spring 2012________Agency__PromptCare, Lawrence, KS – Dr. Elo__Instructor__Karen Fernengel_____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 75% 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 experiencesGradingThe Clinical Performance Tool is completed and submitted by the student at the completion of 60 clinical hours, 120 clinical hours, and all clinical hours for a total of three submissions. The first submission must address items 1-13. The second submission must address items 1-28. 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.Develop individualized health promotion, disease □ □ □ □ x Xprevention and health protection services for adults2/14/2012- Every day, I promote hand-washing as one of the best ways to prevent illness. I promote this by demonstration and encouraging those who are ill and their families to cover their cough with their arm and to wash hands to prevent the spread of illness. I believe I have demonstrate this outcome effectively, however, I believe providing health promotion and disease prevention and health protection information would be more effective for my patients in this clinical setting if my verbal discussions were supplemented with written information, as current discharge paperwork is minimal, and only includes diagnosis (without explanation), meds (often Rx is given) and follow-up information (ex. RTC in 3-5 days if not better). 1/19/12 (19y.o. female), 2/14/12 (13 y.o. female)- I had the opportunity to educate those 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, drinking plenty of fluids, and urinating often to prevent urinary stasis.I do make every effort to ensure patients are taking medication as prescribed and know the importance of following up with their PCP on a regular basis. I am currently working in an urgent care setting, so the opportunities for health promotion, disease prevention and health protection services for adults are not as abundant as they are in a family practice office setting. However, I continue to look for opportunities to provide education in these areas on an ongoing basis and 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 and need for follow-up evaluation of hypertension by their pcp if the patient comes in and is hypertensive in our clinic. 03/13/12- I continue to improve in this area on a daily basis. One was I continue to promote disease prevention is 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. I thought about this quite a bit this winter while caring for patients with URI or influenza like illnesses, and while performing procedures. I thought about it all the time actually, but was even more aware with those more acutely ill patients. Promoting influenza vaccination has also been important during this clinical rotation. Although the late fall months are more common for patients to receive influenza vaccines, I continued to promote obtaining the vaccine to patients throughout the winter and early spring. 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 currently promote the influenza vaccine to my patients and will continue this practice as I continue my career. Another health protection service I provide is personal protective equipment and helmet safety. We see patients with mild traumatic brain injuries (mTBI) as a result of a fall off a bicycle or motorcycle, and often times the patients were not wearing a helmet. They actually present for a hematoma or scalp laceration, but often times these injuries could be prevented with the use of a helmet. On 03/06/12, I saw a 43 y.o male patient who presented with a right elbow injury after an ATV accident. The patient had multiple bruises and abrasions, and a reported concussion (the initial injury was days earlier); the patient was not wearing a helmet or any other personal protective equipment. The elbow x-rays did not reveal a fracture, however, due to the nature of the injury and the continued pain, the patient’s elbow was splinted and he was referred to the ortho practice for further evaluation. 05/03/12 - 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. In the urgent care setting at Prompt Care, the opportunities that arise most often revolve around hand washing and disease prevention like influenza vaccination. If a patient presents with hypertension, then I follow education guidelines re: hypertension according to the JNC 7 report on HTN. First, we always repeat a patient’s BP if elevated in our setting for a couple of reasons, 1) people do get nervous and have the “white coat syndrome”, 2) many people, due to the nature of their illness, are sometimes rushed to get to our clinic and may have a slightly elevated BP on arrival, 3) 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 also educate 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 encourage patients, if they are hypertensive at the clinic, to make an appointment with their PCP and to keep a journal of their BP readings, same arm, same time of day, so they can give that to their PCP at their visit – it might save time later when I know that is probably the first step their PCP is going to take. At the Lawrence OB/GYN Specialists (LOGS) office, I have had the opportunity to assess each patient to determine age specific evidence based screenings that are needed. For example, the CDC has changed the guidelines recently regarding when a PAP test should be initiated and when you don’t need one anymore. The Pap test is one of the most reliable and effective cancer screening tests available, and according the CDC (2012) “You should start getting regular Pap tests at age 21, or within three years of the first time you have sex—whichever happens first.” Other guidelines have also changed, for example, if a patient is 30 years old or older and their past screening tests were normal, their chance of getting cervical cancer in the next few years is very low. Therefore, they may not need another screening test for up to three years. They are still encouraged to see their provider regularly for a check-up that may include a pelvic exam. The patient is also educated about continuing to get a Pap test regularly. If a patient is older than 65 and has had normal Pap test results for several years, or they have had their cervix removed, it may be okay to stop getting regular Pap tests, but they are still encouraged to see their provider for a yearly exam. Since the LOGS office sees a high volume of patients who are seen for annual well-woman exams, knowing these guidelines is paramount in that practice. Prior to this clinical, I was aware of the recent changes in recommendations, but I was not “well-scripted” in those recommendations…now I am! 2. Develop individualized anticipatory guidance and □ □ □ □ x Xhealth counseling for adults2/14/2012- 1/20/12- (30 y.o. female) – Educated pt on alcohol abuse and referred pt to HealthCare Access for further care and testing (pt was self-pay without insurance and needed alcohol counseling and testing for Hepatitis, etc.). Also referred pt to Bert Nash Mental Health Center for alcohol counseling and psych services. Those facilities offer services to lower income patients and have resources for help and treatment for those who do not have insurance. We did not offer those services at our clinic, so we arranged appointments for the patient to facilitate timely follow-up.2/21/12 Although influenza season is under way, I continue to educate patients that it is still not too late to obtain their influenza vaccines. I do this on an ongoing basis. I recommend being up to date on tetanus/diphtheria, and pertussis immunizations (if necessary) for those who patients whom it is appropriate- (1/18/12) – 26 y.o. female with dog bite sustained at work); (1/31/12- 41 y.o. male with hand laceration/repair for hand lac while working as mechanic); (2/14/12- 37 y.o. male with hand lac); ??/??/12 - !! y.o. male pt who presented with a seizure from the evening before; his CC was a headache, sore tongue and fatigue. Pt had a hx of seizures, but had recently moved (last 3-4 months) and since move had reported increase in stress, less sleep, increase in frequency and severity of seizures, and had stopped taking his anticonvulsant meds. Pt was a/o at visit, in minimal distress, and was referred to a neurologist for FU within the week. Pt was educated on the importance of FU, and I offered to make an appointment for the patient if it meant compliance with follow-up. He was educated on the importance of resuming his anticonvulsant meds, and was reminded about not driving or swimming or being alone until FU appointment and further eval was done. Patient also needed to be responsible for self-care and follow-up03/13/12 – In the urgent care setting, the most common form of anticipatory guidance and health counseling that I have had the opportunity to provide is during annual Department of Transportation (DOT) physicals and those patients requesting a yearly physical exam. It is during this exam that unknown health issues arise. During such visits I educated patients on the importance of age or risk appropriate screenings including yearly mammogram (females over age 40; Mammograms are the best method to detect breast cancer early when it is easier to treat and before it is big enough to feel or cause symptoms (CDC, 2012)), Pap test(One of the most reliable and effective cancer screening tests available (CDC,2012)), colonoscopies (Regular screening, beginning at age 50, is the key to preventing colorectal cancer (CDC, 2012)), lipid profiles, Zostavax (Herpes zoster vaccine was licensed and recommended in 2006 for prevention of herpes zoster among adults aged 60 years and older (CDC, 2012), yearly flu shots (a yearly flu vaccine is recommended as the first and most important step in protecting against flu viruses (CDC, 2012)), TDaP (every 10 years unless injury, then sooner), and pneumonia vaccinations (Pneumococcal vaccine is very good at preventing severe disease, hospitalization, and death (CDC, 2012). However it is not guaranteed to prevent infection and symptoms in all people and is not recommended for everyone. 05/03/12- In addition to continuing the above anticipatory guidance and health counseling, I also counseled patients regarding lifestyle modifications such as weight loss (esp. with BMI >30 – obesity), nutrition, exercise, tobacco cessation, and ETOH use. Several patients were seen in the urgent care setting with acute exacerbations of asthma, acute bronchitis, COPD, and URI and influenza in the urgent care setting. Many of those were smokers, who were advised to quit smoking and were asked if they were ready to quit yet. Exposure to second hand smoke was also discussed when children presented with c/o related to asthma, bronchitis, URI, AOM, and influenza. In the women’s health clinic (LOGS), women who were pregnant were encouraged to stop smoking and not consume alcohol during their pregnancy. Since my last submission I have had a few opportunities to practice this independently yet feel that I need additional opportunities to independently practice my skills. My plan for continued development is to practice these skills independently in future clinical rotations. __________________________________________________________________3.Prioritize differential diagnoses based on etiologies, □ □ □ □ x □ risk factors, underlying pathologic processes and epidemiology for medical conditions including acuteand chronic dermatologic conditions, anxiety, depressionbipolar disorder, fractures/sprains/stains, back pain, connectivetissue disease, sexually transmitted infections, incontinence,and men’s health issues.2/14/2012 - 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. Even though I’m in an urgent care setting, I see a large population of patients with a history of hypertension, diabetes, hyperlipidemia, etc. 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, including influenza. Multiple patients present in my clinical setting for DOT/ pre-employment physicals. There have been several occasions where a patient is unable to pass a pre-employment physical or DOT physical and is referred back to their pcp for a work-up on HTN. For example, on 1/18/12, a 31 y.o male patient presents to clinic for DOT physical- fails due to HTN (>140/90 on at least 2 occasions in office); referred back to pcp for eval of existing HTN; can report for DOT physical when his HTN is controlled – for now will be unable to get DOT classification for driver’s license due to underlying uncontrolled HTN. As a result, 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. 03/13/12- I am continuing to improve prioritizing differential diagnoses in this area as I have more opportunities. Since my last submission, I have 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. I use the Ottawa criteria for suspected ankle pain to determine if x-rays are warranted and to help with differential diagnoses (ankle sprain, ankle fracture. The Ottawa criteria are pain near the malleoli or if the patient has the inability to bear weight (four steps) immediately and in the emergency or primary care setting; Bony tenderness at the posterior edge or tip of the malleolus. I use the Ottawa criteria for foot pain for foot injuries as well. I have evaluated several patients with various dermatological problems as well. I still have somewhat of a lack of 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), tinea pedis (110.4), tinea capitis, 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. It did give me some sense of relief to know that my preceptor did not always know what the “rash” was either. My preceptor and I did spend time looking up possible differential diagnoses for more difficult to diagnose dermatological conditions, once identifying a rash on a patient’s hand as herpetic whitlow (054.6). There was another patient whose differentials included pityriasis rosea (696.3), psoriasis (696.1), tinea versicolor, and contact dermatitis. 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. There is also an iPhone app call visualdx that I found helpful, but did not decide to renew the app after the free trial, as it is $100! Depending on the type of job I obtain, I may reconsider. I also think this is a program that Mabee Library was looking into purchasing, which I would recommend. 05/03/12- As I reflect on my growth related to this outcome, I believe I have made tremendous gains in being able to identify 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. The latter part of this clinical rotation was spent with a APRN in an OB/GYN clinic. Since my last submission I have had additional exposure to women’s health exams, including STI screenings, confirmation of pregnancy visits, OB care visits, yearly well-woman exams, post-partum visits and problem visits. The chief complaints during problem visits included breast pain, vaginal pain/odor/discharge, unprotected intercourse/ STI screening, dysuria, to name a few. The problem visits allowed me the opportunity to select differential diagnoses appropriate for their chief complaint. For example, when I saw patients with a chief complaint of vaginal discharge, differential diagnoses included STI, UTI, candidiasis, bacterial vaginitis, genital herpes, gonorrhea, chlamydia, HPV, condyloma, atrophic vaginitis, and PID. The appropriate diagnosis was made after the exam, but I was able to think about all the potential diagnoses before entering the exam room. For patients with breast pain, DD included mastitis, breast mass, candidiasis, glactorrhea, pregnancy, and hormone imbalance. Since the completion of this clinical rotation, I am better able to differentiate acute health problems and women’s health conditions based upon the patient’s presenting risk factors and signs and symptoms. I continue to utilize reference materials 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, which I hope to get in my final semester, I will rely less on resources and my preceptor for guidance._____________________________________________________________________4. Perform comprehensive health history and physical exam □ □ □ □ x X 2/14/2012 – I feel I meet this competency most times on most days. Examples to follow.2/9/12 - I 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 listed on the first page of the patient’s chart and it is 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 in my current setting. It is rare that I would do a comprehensive exam in an urgent care setting. This is a challenge, as it includes timeliness, thoroughness of complete history which includes genogram or at minimum family history, social history, and all PMH. This would also include a thorough skin assessment.03/13/12- I continue to feel I meet this competency with little guidance from my preceptor. I am able to independently perform a comprehensive health history and physical exam. The opportunity for this in the urgent care setting is during Department of Transportation (DOT) and pre-employment physicals. Prompt Care is also an occupational health provider, and as a result, sees multiple DOT and pre-employment physicals on a daily basis. I improved in this area since my last submission mostly in the efficiency in which I could perform these exams. My head to toe assessment is more fluid and natural. On the DOT physicals, 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. Since this is an urgent care setting and I feel comfortable with a comprehensive health history and physical exam, most of my time continued to be spent seeing acute care patients while performing problem focused exams. 05/03/12- The latter part of this clinical rotation was spent in an OB/GYN office with an APRN. 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. Patients presenting for yearly exams and confirmation of pregnancy appointments received comprehensive head to toe physical exams. While I was comfortable with general head to toe exams, adding the GYN assessment is the reason I felt I needed this clinical rotation. I was able to perform more than 30 comprehensive physical exams during this last rotation. These exams also included a clinical breast exam and pelvic exam, and may have included obtaining Pap tests and vaginal cultures, depending on the patient history and chief complaint. There were a few occasions when I had difficulty visualizing the cervix on exam, but was able to complete the exam with some guidance from my preceptor, who has 17 years of experience in this area! Boy does she make it seem easy! One of my interests is women’s health, so I really wanted to get more experience in this area, and I’m glad I did. I feel much more confident in performing female exams than ever before. While there is still room for improvement, I am confident I can perform thorough comprehensive exams on male and female patients, with proper techniques and up to date guidelines. Additional independent practice in this area has assisted me in achieving a higher ranking for this competency.________________________________________________________________________5.Perform problem focused health history and physical exam □ □ □ □ X X2/14/2012- 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 triage nurse obtains the history and meds, and it is clarified and reviewed by the primary provider for that patient. Any necessary changes or additions are documented. A majority of the 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. Since beginning this rotation, 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. I 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. For example, a patient presents with abdominal pain. I focus on the GI system and don’t assess the HEENT, musculoskeletal or neuro systems. So far during this rotation, the majority of patient’s I have seen are HEENT/ Respiratory (URI, influenza, strep throat, sinusitis), or musculoskeletal (shoulder strain, ankle sprain, back pain, knee pain, fractures). Probably more than 90% of the time I have developed the correct treatment plan and most of the differential diagnoses. It is a learning curve in an urgent care setting to determine what tests are necessary and what tests will actually drive your plan of care. Many tests are “nice to know”, but may not change the treatment plan, and are thus unnecessary. This is difficult to adjust to since I come from an ER background and have any test desired at my disposal! I do feel confident in obtaining a health history. I would like to improve my efficiency. As my preceptor has mentioned, it is just a matter of time and of developing clinical confidence with my decisions and treatment options, and plan without the guidance of a preceptor. 05/03/12- 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 with minimal 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, influenza, conjunctivitis, cerumen impaction, mononucleosis, aphthus ulcers, otitis externa, allergic rhinitis, and Eustachian tube dysfunction; Respiratory (CC: fever, cough, wheezing) with final diagnoses including acute bronchitis, CHF, URI, influenza A/B; 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 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.________________________6.Demonstrate diagnostic reasoning and critical thinking □ □ □ □ x □in the development of a treatment plan2/14/2012- 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. My preceptor assures me this is an additional way to practice safe medicine. He believes in double checking yourself and seeing if there happens to be a better option for treatment – no reason to memorize these things if you have available resources that can store the information for me! 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.03/13/12 – 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. I still need assistance at times with clinical decision making related to interpreting x-rays, and prescribing certain medications to help guide me in developing a treatment plan. For example, I had the opportunity to review about 6 ankle/wrist/chest/foot x-rays with my preceptor, and he had me review them first, and then he gave me his interpretation and we discussed the x-ray findings together. I believe I interpreted correctly on all of them, however, I think on one of them we discussed joint spacing for questionable ligament injury, but no fracture was present. That patient was referred to ortho for further eval. 05/03/12- Diagnostic 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 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 300 patients. Again, the latter part of this rotation was spent in a new clinical environment, with the LOGS APRN in an OB/GYN clinic. On 3/29/12, I evaluated a 39 y.o female, G3P2, who was 12 weeks PG; at this visit, we try to listen to FHT with a Doppler at the bedside. I was unable to hear FHT, and neither was my preceptor; using critical thinking, the next step was to order a sonogram that day to confirm viability; the sono reported fetal demise at 8 weeks; the NP I was working with then consulted with the OB doc on call, and the patient was seen right away with that physician and a D & C was scheduled for that day. Emotional support was provided to the patient. Had we chosen to not listen to FHT that day, or not order a sono, this patient would have continued her pregnancy through probably another 4 weeks until her next OB appointment, barring the patient remained asymptomatic until her next visit. Other examples during this clinical rotation of critical thinking include ordering a BHCG for patients who are unsure of their LMP, to confirm PG, or listening to the patient if they say something doesn’t feel right – on 5/3/12, a patient who was 34w2d PG reported that she thought maybe she was leaking fluid; instead of dismissing this to “urinary incontinence”, we did a pelvic exam, and checked the pH, which was low (indicating amniotic fluid presence), did a “ferning test” (negative, indicating no amniotic fluid), then ordering an amniosure test (lab test to indicate presence of amniotic fluid), which was negative, then consulting with the OB doc on call to help facilitate a decision as to whether to send the patient to OB for admission or to send her home to rest – she went home to rest – however, this is a prime example of being thorough and using critical thinking skills to make best practice decisions for your patients, and listening to your patient. 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. At the end of this practicum, I believe I was much more confident and independent in my ability to use diagnostic reasoning to make appropriate clinical decisions. Every patient encounter during this practicum presented at least one problem to critically analyze. 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.7.Initiate screenings appropriate to differential diagnoses □ □ □ □ X □2/14/2012- I 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 refer them to their pcp for follow-up. I 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 take with them at the time of their pcp appointment, as I know this is one of the first things that the pcp will recommend prior to starting someone on an antihypertensive med; I also ask about family hx of HTN, heart disease, etc. I also keep in mind guidelines for TSH screening and lipid disorders, COPD, and DM. While we do not typically screen for thyroid disorders, we may add a TSH and free T4 to their send out labs if we feel they are at risk or if we think hyper/hypothyroidism is a potential differential dx. We would then refer the pt to their pcp. These screenings are often difficult to implement in the urgent care setting, but based on my current and past experiences, I feel comfortable with this competency. 03/13/12 – I continue to feel confident in recommending appropriate screenings based on differential diagnoses, however, in the urgent care setting the three most common screenings we recommend are for STI’s, for those patients who come in with a GU related complaint, and we check a finger stick blood glucose level on all patients getting DOT physicals. We also check a BP on all patients, and recommend follow-up with their pcp if BP is >140/90 on at least 2 occasions in our clinic. Patients do not pass their DOT physicals if their BP is >140/90, or if their CBG is elevated; they are required to see their pcp for further screening and must provide documentation of such visits and have acceptable readings on their next attempt prior to passing. We do field questions about TSH and Lipids, but typically provide education to the patient and recommend follow-up with their pcp, since we do not manage those chronic conditions in the urgent care setting. 05/03/12- This last clinical experience in the OB/GYN clinic 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 be able to “put it all together” really nicely next semester during my last clinical rotation, where I will see a diverse client population. _____8.Initiate diagnostic strategies appropriate to differential □ □ □ □ X □diagnoses2/14/2012- I have had the opportunity to recommend several diagnostic strategies while at Prompt Care. I feel fairly confident when to order x-rays, lab work, and EKGs. I however feel I need more experience in knowing which labs to order and when to feel completely independent in this competency. I also need more experience in determining when a referral to an outside provider is appropriate, or when ordering a CT/MRI is necessary. In order to fully meet this competency, I will continue to seek opportunities to learn more about the appropriate lab work to order based on my differential diagnosis. I will also strive to make more suggestions to my preceptor regarding further testing (MRI, CT, etc.) or needing a referral to Orthopedics, Cardiology, etc.03/13/12- Because of my ER experience where diagnostic strategies are sometimes over-used, I sometimes find myself wanting to do more than what is deemed reasonable! At the urgent care clinic, we can perform point of care testing for x-rays, UA’s, Urine PG tests, CBC, CBG, monospot, EKGs, rapid strep and rapid influenza tests. Other lab work (COMP, TSH, etc.) are send out labs and we do not have those results back for a couple of days. We can order outpatient radiology tests (X-ray, US, CT, MRI) and usually have those results on the same day we order them, but we are careful to order tests, because they have to be resulted during our normal business hours (8a-8p m-f, 11-4 on weekends) or else it doesn’t do us much good to order those tests in an urgent care setting, because we might be sending them to the ED. I often discuss with my preceptor the necessity of performing certain tests and how the results are going to change our plan of care. I feel more confident in this area than I did initially and have been able to look at the bigger picture better. I will continue to look at the big picture when developing diagnostic strategies in the urgent care setting, but also in the women’s health setting at the OB.GYN office, and with future practicum settings. Looking at urgency, referrals, follow-up and necessary POC testing options and patient insurance and financial status are also pertinent when being prudent!05/03/12 - I have continued to develop my skills in recommending diagnostic studies for patients. I am more proficient in some areas than others. I am ecstatic that I was able to complete another clinical rotation in a different patient environment, going from urgent care to women’s health. I was able to pull from my knowledge base, although in a different setting, and take those principles of diagnostic strategies and put them in place in this last rotation. There were times I had to remember, based on EBP guidelines, what was appropriate to order, but my preceptor helped keep me on track, and at a fast pace. At the completion of this practicum, I believe I was routinely meeting expectations for this outcome with minimal input or support from my preceptor in recommending diagnostic strategies to assist in clinical decision making. The value of additional experience and more knowledge allowed this progression in performance during this clinical experience in addition to increased confidence in my assessment skills. My proficiency will increase in extensiveness through practice in the clinical setting, continued education, and increased exposure to a variety of conditions during clinical. I plan to continue utilizing resources to help guide my thinking and to learn from my mentors in order to develop my skills in this area.________________________________________________________________________9. Develop a plan of care utilizing evidence-based practice □ □ □ □ X □2/14/2012- I feel I am able to discuss 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. My preceptor is often times more inclined to write a prescription for a viral illness if he feels that is what the patient or family member is there for. While I feel a more “watch and wait” approach to treatment is more appropriate, he explains that “Prompt Care is a business, and while we strive to treat patients effectively and appropriately, we also are in the business of keeping our patients happy, and if we don’t they will choose another provider next time.” He has many years of medical experience on his side and a great deal of clinical confidence in his practice patterns. While I have inexperience on my side and feel more inclined to a “watch and wait” approach at times, I also feel a need to follow the preceptors practice patterns to an extent. While my preceptor has said that I can do what I feel is appropriate, My preceptor also sees each patient prior to discharge, and has the right to change my treatment plan, and he has on some occasions. He hasn’t said that my plan is incorrect, just different than what he would do, and I wonder if this makes me seem incompetent to the patient, or is just perceived as less experienced. Also, we are not a primary care provider, and often recommend follow-up for patients with their primary care providers, or a “return to clinic if not improved” instruction on discharge. With continued practice, I feel I will become more confident in standing my ground and only prescribing an antibiotic when necessary and not just because the patient wants a “quick fix.”03/13/12- Since my last submission I have developed more confidence in discussing appropriate treatment based on evidence based practice with my preceptor. 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 my preceptor discusses with me is “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. My preceptor is more inclined to put the patient on antibiotics, “to keep the patient happy and coming back next time”, knowing with or without antibiotics the patient is going to improve in the same amount of time. 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 can see the difficulty when patients seem to demand antibiotics “because it worked last time”, and I feel we are just setting ourselves up for future antibiotic resistance! And it puts us as student providers in a difficult situation. In discussing which sources were utilized to frequently access practice guidelines, I mainly used information from the National Guideline Clearinghouse (ARHQ), the CDC website, Buttaro, Epocrates, and the Sanford Guide to Antimicrobial therapy (2011). Drug interactions and dosages were researched mainly using Epocrates and the Sanford guide, as well as the Tarascon pharmacopeia guide (2011) when writing prescriptions. In the OB.GYN setting, the American College of Gynecology (ACOG) guidelines and the CDC guidelines was utilized to determine appropriate EBP; this included when and when not to do a Pap, when and how to screen for STI’s, when Mammograms and colonoscopy should be recommended, and when to do CBEs. The OB/GYN office is up to date on following recommended guidelines and the APRN that I worked with was up to date on current practice and followed the guidelines to a T, making it easy to follow. Overall, the knowledge I gained in my Clinical Scholarship for Evidence Base Practice course has provided some foundation for conducting EBP investigations in the clinical setting. Time restraints, especially in the OB/GYN setting would have made it more challenging had my preceptor not been utilizing up to date EBP guidelines. 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. In closing, I felt I routinely met expectations with minimal support from my preceptor towards the end of this practicum by routinely utilizing EBP information. __________________10. Prescribe medications based on cost, diagnoses, □ □ □ □ X □efficacy, safety, and individual patient needs2/14/2012- I feel that I am able to recommend medications for simple diagnoses I see on a routine basis such as: sinus infections, strep throat, upper respiratory infections, and UTIs. I feel more practice to in prescribing medications for co-morbidities such as: hyperlipidemia, hypertension, diabetes will come with time. I spent most of last semester in a family practice setting dealing mostly with co-morbidities like HTN, DM, Hyperlipidemia, etc., so I am getting the acute care experience and confidence at this time. Putting it all together over time and developing clinical confidence is the next step. I continue to refer to Medscape and Epocrates, as well as the Sanford Guide to Antimicrobial therapy (2011), and Tarascon’s Pocket Pharmacopoeia (2011 Ed.) to improve my medication/prescribing skills on a daily basis.03/13/12- Based on past experiences, I feel that I can recommend medications for frequently seen diagnoses such as depression, anxiety, hypertension, dyslipidemia, and asthma. I have also had many opportunities to recommend medications for frequently seen acute diagnoses such as UTI, URI, Sinusitis, Pharyngitis, Acute Bronchitis, Influenza, Dermatitis, Shingles, Conjunctivitis, Allergic Rhinitis, and Back Strain. I have also been familiarizing myself with newer medications during my clinical rotation that are new to the market and medications that the drug representatives who visit this agency provide. It has been interesting and valuable learning experiences to listen to the drug representatives provide presentations on many of the days that I am in clinical. It is also interesting to see the interactions that my preceptor has with those reps. Before, I somewhat steered clear of them when they came to visit, for fear that I may not know what they are talking about, but as I have gained more knowledge and experience I am able to participate more in the discussions. Specific medications I have become more familiar with include Astepro, Factive, Dulera, Patanase, Pataday, Moxeza, Tamiflu, Avelox, Suprax, Zutripro, and Alvesco. Many of these medications fall outside of my immediate knowledge base, so I look them up on my IPhone using Epocrates. I also know that learning about new medications on a daily basis is going to be standard, as new medications are manufactured and marketed all the time. It will be imperative to stay up to date on these medications, including their interactions with other medications, costs, efficacy and side effect profiles. I am sure that continued exposure and education through my course work will assist in development of my knowledge base and proficiency that will help me to practice more independently and achieve a higher ranking on this competency.05/03/12- Since my last submission, I have obtained more experience in a women’s health setting at LOGS. Throughout this experience, I have become more acutely aware of medications that are safe to prescribe in pregnancy (Ex. Macrobid for UTI, Claritin for allergies, Vitamin B6 and Ginger, Zofran and Reglan for nausea, Pepcid and Nexium for heartburn, Melatonin for sleep). I’m also more acutely aware of what conditions you have to wait to treat (Herpes – cannot use Acyclovir in first trimester – pt must have C-section to avoid risk to baby if active lesions present; Yeast – Diflucan category C in pregnancy; Flagyl contraindicated to treat trichomoniasis in first trimester – FDA category B but trimester specific). Overall, I have become more conscientious as to what medications to prescribe to certain populations based on cost as well – Ex. - knowing that Medicare won’t pay for certain brand name medications, so sometimes that may require prescribing a different class of medication so the patient can afford it, or may mean giving a sample of a new drug so the patient doesn’t have to pay at all. On 4/17/12, I evaluated a 68 y.o. female patient with Allergic Rhinitis – since the patient was on Medicare, I gave her samples of Astepro (nasal antihistamine), and Nasonex (nasal corticosteroid), and a RX for Flonase (if she liked the relief from Nasonex). I also had an 88 y.o. male with long hx of intermittent Bronchitis, and was allergic to Zithromax; I wanted to RX Levaquin, as the patient had a hx of COPD, but since the patient was on Medicare, I knew the Levaquin would not be covered, so I gave the patient a 10 day sample of Avelox which we had in the clinic. Whether or not we want to believe it, a patient’s financial status and what insurance they may or may not have and the drug companies all have an effect on how we prescribe medications and what treatments we suggest. All of those factors must be considered individually based on a patient’s need. I plan to continue to be aware of each individual patient’s needs and plan to base my care accordingly to the best of my abilities. _____________________________________________________________________________11. Perform medical and surgical procedures as appropriate □ □ □ □ x X2/14/2012- I have had a handful of opportunities to perform procedures, including: 1/20/12- pelvic exam on 38 y.o. female with c/o vaginal discharge - pelvic exam normal, white dc noted, consistent with vaginitis- candidiasis; given RX for Diflucan. Pt agrees with plan. 1/20/12- 20 y.o. male presents with “boil on butt”,; I performed I & D of abscess to the left buttock, with packing; pt tolerated procedure well; was to return to clinic in 2 days for recheck, given RX for Bactrim DS and Lortab for pain. 1/26/12- 2 y.o. male with scalp lac – applied Dermabond for wound repair. Pt tolerated well. 1/31/12- 21 y.o. male with lac to left elbow left elbow after fall on concrete while playing basketball; used 1% buffered lidocaine for anesthetic; used 4.0 nylon suturing (#4). 2/3/12- 23 y.o. female presents with suprapubic abdominal pain; pelvic exam performed – cultures obtained; exam normal. 2/3/12 – 5 y.o. male patient with laceration to bridge of nose – applied Dermabond. 2/7/12 – 12 y.o. male with ingrown toenail – performed digital block (64450) and toenail removal (11765). 2/7/12 – 24 y.o. male with pilonidal cyst x 1 week; performed I & D of cyst with nugauze packing; 2/14/12- 37 y.o. male with left hand laceration at work – performed lac repair, using 1% buffered lidocaine for anesthetic, and 4.0 nylon sutures for repair (13 sutures!). I am beginning to feel more confident in assisting with medical and surgical procedures; however, performing procedures on my own is one area improvement is needed. It is still reassuring to have someone looking over my shoulder to make sure I am doing it correctly. I have been able to help assist with multiple I & Ds (which I am becoming more confident in performing solo), suturing, and splinting (feel fairly confident applying splints with my ER background). 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. I am also planning on spending about 40 hours with a APRN at the Lawrence OB/GYN office, practicing more women’s health assessments and procedures. 03/13/12- I continue to have experiences with medical and surgical procedures in the urgent care setting. On 2/28/12, I performed a digital rectal exam with hemocult testing on a 75 y.o. Asian female patient with a c/o LUQ abd pain – the exam was normal, hemocult negative; pt tolerated procedure well. On 3/13/12, I excised 3 viral warts on the right hand, of a 17 y.o. male pt, using 0.5% Marcaine for local anesthetic; the patient tolerated the procedure well. On the same day, I examined a 23 y.o. male patient with c/o right eye pain; Tetracaine was inserted into his right eye and the wood’s lamp was used to facilitate the dx of a scleral abrasion. The patient was subsequently RX Vigamox eye drops and was a worker’s comp injury; he was instructed to return to the clinic in 2 days for a follow-up exam. He tolerated the procedure well. I have also had the opportunity to perform several pelvic exams; this is a procedure I anticipate having to do often in my practice setting someday, therefore the experience is invaluable and I appreciate each opportunity to perform these exams. Since I have a special interest in women’s health issues, I feel this is an area I need to have more clinical experience in and more confidence in performing. I do feel more confident than when I started and have learned different techniques with each preceptor. They have all had great tips to remember, so putting it all together is the key!05/03/12 – I have been fortunate enough to continue to have opportunities for procedures in the urgent care setting. 03/28/12- Performed excision of an ingrown toenail on a 52 y.o. male pt using Marcaine 0/5% and a digital block for anesthetic. I then used a cautery pen to minimize any active bleeding after the procedure. On 4/17/12, I placed 8 sutures (nylon) to the forehead of a 32 y.o. male patient, workers comp injury, who sustained a laceration to his forehead when a co-worker hit him in the head with a metal pole. The patient did not have other injuries, neg. ROS otherwise. 1% buffered lidocaine was used for local anesthetic. I continue to improve my skill set in this area, and although still quite slow in my opinion, my sutures look nice and I am getting more proficient and confident in this skill. I still feel I have a long way to go to being efficient and confident, but I am getting there, and look forward to every opportunity. Also on 4/17/12, I had the opportunity to remove 3 skin tags from the anterior neck, and 2 viral warts (757.39) on the left forearm, from a 26 y.o. Male patient. I used scissors and a cautery pen to remove the skin tags, and used 1% lidocaine for local anesthetic and an 11 blade scalpel to cut off the warts, then used a cautery pen on them. The patient tolerated the procedure well. Medical procedures in the OB/GYN office setting included over 30 clinical breast exams (CBE) and pelvic exams, with the majority of them including a Pap test; using a handheld Doppler to assess fetal heart tones; measuring fundal height on patients >20 weeks gestation; observing insertion and removal of a pessary and IUD’s, and conducting multiple STI screenings, as well as obtaining wet mounts and vaginal cultures. Throughout this clinical rotation, I feel I have been exposed to and have had the opportunity to perform a variety of medical and surgical procedures. I feel I have done enough different types of procedures that I could do many on my own in a clinical setting and feel comfortable since I have done it a few times before, and not just read about it or observed it. As always, obtaining additional exposure with increased independence will assist in me mastering those skills. 12.Interpret patient responses to treatment and recommend □ □ □ □ X Xchanges to the treatment plan as indicated2/14/2012- In my current setting, I see acutely ill patients, and their response to treatment is sometime fairly rapid. Also, because of the nature of being an acute care setting, we often don’t see the patient again for follow-up, assuming the patient is improved! We tell all of our patients to return in 2-3, or 5-7, or 7-`0 days (common FU plan), if not improved, sooner if worse. Some examples of acute response to treatments are provided: 1/20/12- 20 y.o. male with pilonidal cyst, recurring, I did an I & D of abscess – provided immediate pain relief after drained; was referred to surgeon for recurring problem, in hopes to keep cysts from recurring in future; given Lortab and Bactrim DS for home. On same day, saw 23 y.o male with foreign body in eye – work related; used woods lamp and slit lamp, removed FB, providing immediate relief. Rx for vigamox and lacrilube given. 1/26/12- 9 y.o male pt presents with n/v and abdominal pain since prior evening; given Zofran ODT in clinic, labs drawn (CBC), UA collected and po fluids given after 30 minutes; pt condition improved, and able to keep down po fluids on DC; given RX for Zofran, DX acute gastritis; pt was wheeling around on stool in room at DC, a sure sign of improvement! 1/31/12 – 2 y.o. male pt with acute right ear pain; crying and screaming on arrival; PE revealed ROM, inserted topical analgesia - antipyrine/benzocaine otic gtts in right ear; within 5 minutes pt was resting comfortably with no c/o; given RX for Zithromax, as was recurrent infection, recently on amoxil for same dx.; asked parents to do the “watch and wait” technique, using topical analgesic drops prn for 1-2 days and OTC analgesics like acetaminophen and ibuprofen, and then start abx in 2 days if not improved; parents vu, agreed to try watch and wait technique. 05/03/12- As stated above, in the urgent care setting, I see acutely ill patients, and their response to treatment is sometime fairly rapid. Also, because of the nature of being an acute care setting, we often don’t see the patient again for follow-up, assuming the patient is improved! We tell all of our patients to return in 2-3, or 5-7, or 7-`0 days (common FU plan), if not improved, sooner if worse. Patients with lac repairs or office procedures could be evaluated for acute response to treatment (i.e. lac repair looks good!); Even when doing joint injections or trigger point injections, it is impossible to evaluate response to treatment unless the patient returns for worsening or in a couple weeks because they want another injection. It is easier to evaluate immediate response to treatment if splinting an ortho injury, as they often feel better once the joint is immobilized. It is also easy to evaluate response to an albuterol treatment in a patient who presents with wheezing or an exacerbation of asthma or COPD. In the OB/GYN setting, we see patient’s regularly for follow-up if they are an OB patient (every 4 weeks up to 28 weeks, then every 2 weeks, then weekly until delivery); we do not see annual exam patients for follow-up unless necessary. All pap test patients receive their Pap results in the mail via a standard letter. Patients with abnormal results are personally called, including abnormal Paps, STIs, vaginal cultures or those with abnormal lab results. These calls are typically made by the office nurse or med aide after consultation with the APRN or physician. 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. ____________________________________13.Document using professional terminology, □ □ □ □ X Xformat and technology (i.e.: ICD9, E/M coding, CPT)2/14/12 – Prompt Care uses a written documentation system called a PiVot sheet, tailored to the patient’s chief complaint by the front office staff, then printed out and used for the primary provider’s documentation. We free text our assessment details if the pivot sheet is not as accurate as the patient’s chief complaint, or if the chief complaint changes or there is more than one chief complaint. Laceration repair and radiology interpretation and procedure pivot sheets are printed separately and specific to procedure, in addition to the basic pivot sheet. I check boxes for pertinent negatives, or a box for normal findings. At the end is a list of many potential differential diagnoses, and we pick the box that is the appropriate diagnosis for that patient. If the correct diagnosis is not listed, there is a space for us to write in the diagnosis and the ICD9 code. The Pivot sheets also include option of adding additional notes or terms or free text writing, such as “consistent with yeast or candidiasis”, etc., areas for writing SOAP notes, orders, hand drawn pictures when needed, etc. When the Pivot sheet is complete, it is scanned, and the billing is done off the Pivot sheet by the computer documentation system, and is double checked by the front office staff for completeness. In my current setting, we have a rapid coder cheat sheet that lists the most common ICD9 codes in family practice/internal medicine. I use this sheet daily to identify the correct ICD9 codes. Also, I have at least 2 ICD9 apps on my iPhone (ICD9 consult, and STAT ICD-9) that help when I need to find a code that isn’t on the “cheat sheet”; the apps are quick, useful and free. 05/03/12- Since my last submission, I have continued to use the PiVot sheets in the urgent care setting, 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. While at the LOGS office for the latter part of this clinical rotation, we used Cerner computerized documentation in PowerChart. You have to select the right template diagnosis (E.g. Well woman exam, antepartum – initial visit, antepartum visit, confirmation of pregnancy visit, post-partum visit, vaginal discharge visite, 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 last semester in my clinical setting, 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 was 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 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. Recognize need for referrals by collaborating □ □ □ □ □ xand consulting with members of the health care team03/13/12- Patients are often referred to other providers due to specialized care or limitations of services we are unable to provide in the urgent care setting. On 02/21/12, I evaluated a 53 y.o. female for right leg weakness that had been present for several weeks. The patient had an extenuating psychosocial background which made the exam more difficult. The patient did not leave her house very often, and on exam, I could not rule out a prior CVA episode. My preceptor evaluated the patient, and we agreed to call the patient’s PCP for a consultation. Since it was late in the evening, we made a decision that it was not an emergency to do a CT on this patient, and consulted with the patient’s pcp, who agreed with the plan and was going to see the patient first thing the next morning, and determine further needs at that time. On 2/28/12, I evaluated a 56 y.o. female patient with epigastric/abdominal pain; after a normal cbc, digital rectal exam with a negative hemocult test, and the need for an ECG was ruled out, the patient was referred to a GI specialist for further work-up. Also on 2/28/12, I evaluated a 10 y.o. female patient with a rash on her arms and face. It was determined to be contact dermatitis (ICD9 692.9), and she was treated with Orapred, and the patient was referred to a dermatologist if not improving. We wouldn’t typically refer a patient with a rash, but it was a little odd and even my preceptor was unsure, and because the dermatologist who has an office next door was gone for the day, we treated the patient and told her to return for worsening or if not improved in 2-3 days to see the dermatologist. On 03/06/12, I saw a 43 y.o male patient who presented with a right elbow injury after an ATV accident. The patient had multiple bruises and abrasions, and a reported concussion (the initial injury was days earlier); the patient was not wearing a helmet or any other personal protective equipment. The elbow x-rays did not reveal a fracture, however, due to the nature of the injury and the continued pain, the patient’s elbow was splinted and he was referred to the ortho practice for further evaluation. A call was made to the ortho physician on call that day, to discuss the injury and x-ray results, and to schedule an appointment for the patient. 05/03/12- Since my last submission, I have had more opportunities to collaborate and consult with other members of the health care team. I had a 43 y.o. female patient on 3/28/12 with SVT – treated, resolved on own, but patient probably had history of same, so referred back to PCP and also recommended referral to cardiologist. I referred a patient to orthopedic surgeon for evaluation of left Maisoneuve fracture of the fibula – splinted appropriately in clinic setting, and consulted via phone with orthopedic physician and recommended follow-up due to injury. Several orthopedic injuries resulting in fractures were diagnosed, properly splinted and referred to the orthopedic office for further evaluation. The orthopedic physician was called and consulted if the fracture was more severe and needed to get in more urgently for follow-up. As needed, and without hesitation, we also referred patients to GI, Urology, cardiology, OB, and ENT. We consulted regularly with the radiologists regarding diagnostic procedures and results. We also consulted with the patient’s primary care providers as needed. In the OB/GYN setting, working with an APRN, we consulted with the on-call physician as needed, which wasn’t very often. On one occasion, we had to refer the patient to the on-call physician after a sono revealed fetal demise. On another occasion, we referred a patient to the on-call physician after the patient felt like her bag of water broke after a sonogram in the office, and we saw her for her exam after that. In the OB/GYN setting, we did not hesitate to refer or consult with the pcp if needed. We also referred several patients to high risk perinatologists as needed. For example, if a patient had gestational diabetes, they were referred to a perinatologist for a special high risk ultrasound, or if they had a high risk pregnancy they were referred. 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 future clinical rotations and in practice______________________________________________________________________________15. Discuss access, cost, efficacy and quality when □ □ □ □ □ xmaking care decisions02/28/12– I saw a 47 y.o. patient dx with with a peritonsillar abscess – pt was self-pay patient and did not have insurance, so referred initially to Health Care Access on same day so they could utilize their services to have free referral to ENT doctor, who patient saw on same day, for drainage of peritonsillar abscess –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.05/03/12- The urgent care clinic I did most of my clinical rotation in sees only patients who have insurance or are self-paying patients. They do not accept Medicaid, and you have to pay up front for services, otherwise you are not seen at that clinic. If we felt a patient needed more care than we could provide, or if it was getting costly and the patient was a self-pay patient, we sometimes referred the patient to the ER at the local hospital, or referred them to HealthCare Access, the local clinic for patients without insurance. We did our best not to order unnecessary tests on any patients. Prescriptions were written based primarily on EBP guidelines, and then based on insurance or ability to pay for certain RX, or they might have been given a sample of a med, if it was comparable to what we were going to write the RX for. I do not feel like efficacy or quality was compromised in providing care for any patient in the urgent care setting. Access was an issue if you did not have insurance or funds for self-pay; options were always discussed with the patient in all circumstances so they were a direct participant in their care. At the OB/GYN office, they treated patients of all funding types, including Medicaid and self-pay patients, in addition to those with insurance. They did not, however, see patients without setting 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. 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. ______________________________________________________________________________16. Perform care in a timely manner □ □ □ □ x □03/13/12_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 urgent care setting, I can be in and out of a room in 5-10 minutes, depending on the patients’ chief complaint. In the women’s health clinic, the patients are scheduled from 10-30 minutes depending on their visit reason, from “confirmation of pregnancy” (10 minutes), to “pregnancy visit” (20 minutes), to “annual exam” (30 minutes). Dr. Elo at Prompt Care reported that “clinical confidence comes with time”. 05/03/12 -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 in my education, 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. Jan Morey, APRN at Lawrence OB/GYN Specialists says “It takes time to run a tight, efficient schedule”. So, while I feel like I should be quicker, I also realize I am trying to keep up with providers who have been practicing 15-20 years. I also feel like I don’t want the patient’s to feel rushed. As I continue my education, I realize there’s still room for improvement, and feel that efficiency will improve with each passing semester. ______________________________________________________________________________17. Maintain confidentiality and privacy □ □ □ □ □ x03/13/12- 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.05/03/12- In addition to continuing the above practices, 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 preceptor. Meeting this outcome is a priority in every health care environment and interaction. My preceptor 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 □ □ □ □ □ x03/13/12-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.05/03/12 – 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. 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! ______________________________________________________________________________20. Employ effective communication methods with patients, □ □ □ □ □ xfamilies, preceptor, and staff03/13/12- 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. Dr. Elo and I have a good working relationship and he knows he 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. Dr. Elo feels like it is his role to be a good role model and teacher and know that individuals who will someday be working beside him have been properly trained. 05/03/12- In addition to continuing the above practices, 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. ______________________________________________________________________________21. Provide culturally competent care to patients □ □ □ □ □ xand families and negotiates a mutually acceptableplan of care03/13/12_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. 05/03/12- In addition to continuing the above practices, I continue to be sensitive to other cultures. 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”. I plan to continue to develop an understanding of the belief systems and preferences of the diverse populations served in our area are helpful in providing effective care. Being sensitive to patients with disabilities was 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, etc. to assist with mobility needs. ______________________________________________________________________________22. Communicate practice knowledge effectively both □ □ □ □ □ xorally and in writing03/13/12- 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 preceptor also felt I made 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 (Prompt Care uses PiVot paper documentation, 05/03/12- Lawrence OB/GYN office and LMH use Cerner computerized Powerchart documentation) and preference for presenting patients from a student and preceptor perspective. 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._____________________________________________________________23. Apply available evidence to continuously □ □ □ □ □ ximprove quality clinical practice05/03/12- 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 referenced Ferri’s clinical advisor and Epocrates daily. I also utilized 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 and other guidelines and websites as appropriate. My preceptor is supportive and encourages 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. He 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 both looked up information together, often times seeing who could find the information the quickest, using different sources. 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.___________________24. Utilize appropriate agency educational tools □ □ □ □ □ xto provide effective, personalized health care topatients and caregivers_05/03/12- In the urgent care setting and in the OB/GYN 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 not any educational tools available to patients and caregivers. They did not have handouts for anything other than meds from drug reps. In the OB/GYN setting, I was given copies of processes for different patient types and presentations (egg. How to chart and do the exam systematically on a new OB patient). There were also multiple handouts on multiple topics in every patient room and in the lobby of the office. These were readily available to patients at all times, and were referred to and handed out when appropriate. I feel the urgent care setting patients could have benefited from having education handouts on various topics, from allergies, to asthma, to flu vaccines, to STI’s and sinusitis and URIs, etc., but those items cost money, and some for-profit agencies are not willing to spend money on those types of things. I did not hesitate, however, to pull out my phone and share educational information with patients or caregivers/preceptors, if I felt it was 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. _____________________________________________________________________________25. Coach the patient and caregiver for positive □ □ □ □ □ xbehavioral change05/03/12- 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._________________________________________________________________________26. Demonstrate information literacy skills in complex □ □ □ □ □ x decision making05/03/12- My ability to define patient problems and apply a systematic approach in obtaining histories and performing comprehensive and focused physical exams based on patient presentations demonstrates information literacy skills in complex decision-making. I am developing the 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. 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, as discussed in above questions, will facilitate learning and will continue to demonstrate information literacy skills while making complex decisions. ______________________________________________________________________________27. Integrate ethical principles in decision making □ □ □ □ □ x05/03/12- 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 planto 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.___________________________________28. Demonstrate respect, compassion and integrity □ □ □ □ □ x03/13/12_ 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.05/03/12 – As I continue my clinical practice, my thoughts and actions remain the same as stated above. 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. 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 clientsx?Submission #1 after 60 hours of practicumStudent Signature______________________________________Date____________________Faculty Signature______________________________________Date____________________Submission #2 after 120 hours of practicumStudent Signature_____________________________________Date____________________Faculty Signature_____________________________________Date____________________Final SubmissionStudent Signature_____________________________________Date____________________Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade:November, 2011Revised 1/23/12 ................
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