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Washburn UniversitySchool of NursingNU 607 Health Care Practicum II- Specialty (Adult) Clinical Performance Tool(Completed by Student and Faculty)Student: Krystal Morris Semester: Spring 2012Agency: Mt. Oread Family Care Instructor: Gail CiesielskiClinical 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 □ □ □ □ □ □prevention and health protection services for adults60 Hours: Rating 3Every interaction in the clinical setting presents the opportunity for primary prevention strategies. For example, I develop individualized health promotion and disease prevention plans when I ask about immunizations for all age groups. Many of the well child visits that we do in the clinic present the opportunity to discuss the importance that vaccination plays in the health of children. The start of this semester begun right in the middle of cold and flu season. I always ask patients if they received their influenza vaccination for the year and if they are at high risk for pneumonia, I inquire about the pneumococcal vaccination. With any age group, it is appropriate to discuss seatbelt use and avoiding tobacco whether it be smoking or being around secondhand smoke. After 60 hours, I have a goal of becoming more independent with this outcome where I would describe myself as being proficient and require little guidance from my preceptor. Health promotion and protection are going to play a large role in my future career, therefore I recognize the importance of striving for a 5 by the end of 180 hours.120 Hours: Rating 4-5After an additional 60 hours of clinical time, I have become more efficient in individualized health promotion. I have seen numerous patients with tobacco abuse disorders and have become more comfortable in addressing this habit that has long term health consequences. One patient in particular sticks out from the rest as she was being seen for the 3rd time in 2 months for COPD related problems. She was a 40 pack year smoker, didn’t regularly use her long term inhaled corticosteroid, and continued to smoke despite starting on supplemental home oxygen. I discussed how important it was for her to quit smoking because she was putting herself in additional danger by smoking with oxygen. She said that she smokes in her home even if her grandchildren are present. I provided health promotion through reviewing the dangers of secondhand smoke. I suggested smoking outside when they are around as well as changing clothes and washing hands prior to holding them. We also discussed the incidence of oxygen exploding while patients are smoking on O2. After the discussion, she said that she didn’t know she could “blow herself up.” The patient asked for a prescription medication to aid with smoking cessation. She was started on Wellbutrin, as she had already tried Chantix in the past and experienced hypersomnia and night mares. By the next visit a few weeks later, the patient reported that she has cut back to 2 cigarettes per day and only smokes outside after removing her 2L O2. At my clinical site, we perform many well woman examinations. This provides a wonderful opportunity to incorporate health promotion and disease preventative maintenance. No matter what age, I inquire about STD/HIV risk factors such as multiple sexual partners. I always ask about birth control measures as well as protected sex. I recently saw a patient who was at the clinic for a Med refill completely unrelated to women’s health. I got to asking her how everything was going and she starting telling me about painful, foul smelling urination as well as increased vaginal discharge, worse over the past 2 months. When I asked about sexual partners, she reported being in a monogamous relationship. In further discussion, it was revealed that she is an exotic dancer and often shares costumes, including underwear with other women, often after they had worn them earlier in the night. This presented a perfect opportunity to discuss STDs and safe behavior. She was scheduled for a follow up well woman visit to further address her women’s health issues.With every well woman visit, I also ask about tetanus and influenza vaccination as well as any past abnormal pap smears or mammograms. 180 Hours: Rating 5 Looking back over the past 180 hours, I recognize that I have grown and become independent with this outcome. I originally had thought after 60 hours that I was functioning at a 4, when realistically I see I was more at a 3 as my preceptor often reminded or prompted me on what type of health promotion I should be offering my patients prior to my interaction. I have become very comfortable incorporating health promotion and disease prevention into every patient interaction, and now see this as one of my strengths. Per the CDC guidelines, I recommend a colonoscopy for men and women 50 and above and a mammogram for women 40 and above as part of disease prevention and screening. As part of health promotion, I encourage adults to be seen by their primary care provider annually for a routine physical to screen for HTN, hyperlipidemia, diabetes, and other disease processes and needs that could be identified early on.2. Develop individualized anticipatory guidance and □ □ □ □ □ □health counseling for adults60 Hours: Rating 4Anticipatory guidance occurs through every stage of life. In my current clinical setting, we have performed several well child visits. With this type of visit, I always bring in literature regarding what to expect at each stage of infancy through older childhood. This handout presents parents with basic information of what to expect as far as growth and development, behavior changes, etc. Providing anticipatory guidance requires some degree of learning how to read people. Basic conversations can often be the gait way for recognizing knowledge deficits. Patients often clue you in on areas and topics where additional education and guidance is necessary. Anticipatory guidance is offered based on different stages of life. For example, with teenagers, I always question seatbelt use. With this age group, I also ask about drinking or drug use. With these questions I tie in the importance of being safe when under the influence by not drinking and driving. With older adults, anticipatory guidance includes fall prevention and medication safety.120 Hours: Rating 4.5Anticipatory guidance and health counseling continues to be a routine part of all patient interactions. With the previous outcome, I discussed well woman visits. When women are reaching menopausal age, we review what changes to expect, and I do my best to answer all of their questions and concerns. When patients of child bearing age come in, birth control is always a key point to health counseling for me. I have had many teenagers/young adolescents say that they don’t use birth control because they “probably wouldn’t get pregnant” or a few have mentioned a baby may be a good addition since they are in a difficult relationship. I really try to listen to individual concerns to guide my education process. Although birth control of protected sexual experiences seem like important factors to me, I realize they are not the goals of everyone else. For a female who refuses to have protected sex, I recommend coming in annually instead of every 2-3 years for a pap smear with STD screen. When the teenager told me a baby could be a good addition to a troubled relationship, I was able to further counsel the patient about personal goals with having children. At one point she asked if they were even all that expensive, that there were programs out there to help her financially if she were to become pregnant. We also saw a patient who had been seen in another clinic for pregnancy termination for the 3rd time. She was being seen at my clinical site for anxiety and depression. She presented the opportunity for the conversation about avoiding pregnancy and STDs. I have been able to provide health counseling to many obese patients in my clinic. Many of the obese patients that I have seen have become discouraged because they have tried so many diets without results. With further investigation, many of the patients tried rapid weight loss diets, diet pills, etc instead of making overall lifestyle changes to help with weight loss. We often discuss portion control rather than minimal eating which leads to a feeling of starvation. Last semester, my preceptor was a supporter of the weight watchers program. With this program, you are still able to eat the foods that you enjoy, it just has to be in moderation. If you decide to eat a big piece of cake with lunch, then you need to eat healthier foods with less points at dinner. I have discussed this meal plan with several patients who left the office feeling empowered to lose weight. I think it is reassuring to people that they don’t have to cut out everything they enjoy in order to lose weight. People are less likely to be compliant with a diet without some type of personal enjoyment. 180 Hours: Rating 5After 180 clinical hours, I feel that I consistently develop individualized anticipatory guidance and provide health counseling with little guidance from my preceptor. Before going in to see a patient, I am able to look through their past records if they have any and develop a plan for things to talk about before starting the interaction. For example, if they were seen for the past visit for COPD and they are a current smoker, I make sure to incorporate the importance of smoking into every visit. My preceptor recently discussed with me an article about the role that health care providers have in the influence over smoking cessation. He told me that the article says that studies have shown that if the only thing a healthcare provider can do is to get their patient to quit smoking, it makes a greater impact in their overall health and longevity than managing any other co-morbidities. Ever since we had this discussion, I have discussed this with almost every patient we have that is a smoker. I was shocked that so many people are surprised to hear that smoking can so negatively impact your overall health and longevity. I have become comfortable with anticipatory guidance with well child visits as well. For example, with 15 month old check-ups, we discuss toddler safety that includes making sure your home and anyone who watches your child’s home is an overall safe environment. I discuss water safety with them, as drowning is the #2 cause of death at this age as well seatbelt and car seat safety. Anticipatory guidance also includes fire safety, and beginning to think about starting to toilet train, although it is a little to early to start thinking about right now. Anticipatory guidance is often driven by the patient interaction. For example, when I was asking a 15 year old how school was and what activities he was involved in, he told me “partying on the weekend.” When I asked about drug or alcohol use, he laughed and said “sometimes, but I’m a good drunk driver.” This presented the opportunity to discuss the dangers of driving under the influence, the repercussions with the law, what could happen if an accident occurred, and overall how this decision could impact his future. I was careful about how I phrased this interaction, and I felt like it was a positive interaction until he said, “you must be getting old and don’t know how to have fun anymore.” I continued to reinforce my suggestions and advice.3.Prioritize differential diagnoses based on etiologies, □ □ □ □ □ □ 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.60 Hours: Rating 3I have seen personal growth when transitioning from Adult Health I to Adult Health II with this outcome. As my knowledge base has expanded, I find myself being able to develop differential diagnosis with less help from my preceptor, although I recognize this as a weakness. My personal goal for this outcome by the end of the semester is to be able to independently formulate 5 differential diagnosis for each patient that I see. Right now, for most patients I can formulate approximately 2 differentials without the assistance of my preceptor. As I am becoming more comfortable in obtaining a thorough health history and review of systems, I feel that I am more in tune with additional things to look for in my clinical assessment. I would rate myself a 3 at this time because I still bounce my thought process for my differentials off my preceptor. 120 Hours: Rating 4I have seen personal growth with this outcome and find myself far more independent with formulation differential diagnosis than I was at the beginning of this clinical rotation. With most patients, I continue to be able to come up with 2-3 differential diagnosis and have a treatment plan in mind that would correspond with each differential. As far as prioritization of differentials, I can usually do this independently. If a patient comes in with chest pain, a MI and GERD are among my differentials. An MI is life threatening with immediate consequences, so I understand further investigation into the chest pain to rule in or rule out an MI is very important. 180 Hours: Rating: 4-5At 60 hours, my goal was to be able to independently formulate 5 differential diagnoses at the end of 180 hours. I have met this goal. For example, last week I had a patient with a generalized rash on his right leg. I was able to come out and list 5 differentials although I was 99% certain that the patient had poison ivy, a contact dermatitis based on his clinical presentation and history. We also saw a patient for acute ankle pain last week and I was able to formulate 5 differentials along with various assessment techniques to rule in or rule out my differentials.I was able to prioritize differential diagnoses when I did some clinical hours in the hospital setting. We had a patient present to the ED reporting that he was “having a lot of withdraw symptoms lately.” The patient reported drinking heavily up to 2L of vodka/day for the past 3 days. He had a history of seizures that he took Librium for, a history of falls, SIRS criteria (WBC high, tachycardia), possible head injury, and alcohol withdraw. With this experience, I learned to prioritize my diagnoses with SIRS criteria with known organ failure being identified as my number one diagnosis. With this presentation, the patient could end up in multiple system organ failure if his needs are not quickly identified. ________________________________________________________________________4. Perform comprehensive health history and physical exam □ □ □ □ □ □ 60 Hours: Rating a 3I have had very few opportunities to obtain a full comprehensive health history in the clinic setting. I currently rate myself at 3, as I know that this is one of my weaknesses since I have had limited exposure to full health histories. Most of the time our clinic patients require problem focused histories. It is my goal to become more proficient and have more exposures to comprehensive histories. As far as performing a physical exam, I feel that I am routinely able to assess a patient without assistance from my preceptor. There are times, especially when it comes to dermatologic conditions that I need to review appropriate terminology for describing the condition or lesion. I recognize that this particular system is one of my weaknesses, and as a goal, I am putting forth effort to more independently assess and describe skin conditions. I also have become more confident in my overall assessment skills, especially with identifying abnormalities. I can perform a comprehensive health history and complete physical exam in a much more timely fashion that I could in my previous semester. 120 Hours: Rating a 4I recently discovered that although I felt I was performing very thorough comprehensive health histories, there was room for improvement. The comprehensive histories that take place in the clinic vs the hospital setting are very condensed. In the clinic setting, the interview for my health history would take 5-10 minutes with equal time to document afterwards. I recently did clinical time in the hospital setting where I had the opportunity to perform comprehensive health histories for inpatient admission. These interviews took me on average 15 minutes to obtain all of the pertinent data along with another 45+ minutes to fully document the comprehensive history, physical exam findings, and plan. Over the two shifts that I have been in the hospital so far, I notice growth and improvement in my interview skills and being able to obtain all pertinent information. I have also learned that many conversations need to be redirected in order to obtain a history in a timely fashion. With some of the side stories that patients offer me, I could spend a very long time gathering health history data. I have a few more shifts in the hospital setting, and it is my goal to be able to perform a comprehensive health history, physical exam, and full documentation in <45 minutes. 180 hours: Rating 4-5Since my 120 hour submission, I had the opportunity complete 2 more days of clinical time in the hospital. I independently collected and completed several complete health histories and physical exams during this time. I feel that I have met my goal that I set after 60 hours at becoming more proficient at a comprehensive health history, and I no longer consider this an area of weakness. In my 60 hour submission, I discussed how dermatologic conditions are one of my weaknesses, and I set a goal to independently assess and describe skin conditions. I feel like I have met this goal as I have put forth effort to broaden my vocabulary and descriptions of dermatologic conditions as well as being able to diagnose them. ________________________________________________________________________5.Perform problem focused health history and physical exam □ □ □ □ □ □60 Hours: Rating between a 4 and 5In general, I perform more problem focused health histories and physical exams than I do comprehensive health histories. Many of the patients that we see are established patients, therefore obtaining a comprehensive history is not necessary. At some point in obtaining a problem focused health history, I always ask if there have been any changes in medical conditions since they were previously seen in the clinic. This ensures that records and medication lists are up to date. At this point, I wound rate myself between a 4 and 5 because I independently go see my patients and perform an assessment without my preceptor. Occasionally, he goes in and adds on the history that I obtained. After 60 hours, I see being able to collect a problem focused health history one of the strengths.120 Hours: Rating 4.5-5When looking at my performance between a comprehensive health history and a problem focused exam, I have had much more exposure to performing problem focused exams. The majority of the patients that we see need a problem focused history unless they are a new patient. On average, I would say that I perform a problem focused history in 5 minutes in or less including computer documentation. I have become increasingly efficient at typing my history and pertinent information as I go rather than doing so afterward. I have become more systematic in my approach of documentation of subjective/review of systems. I usually start with the system of the chief complaint and review associated symptoms after further investigation to the main reason they are being seen. 180 Hours: Rating 5I rate myself at a 5 for this outcome, as I have the opportunity to independently perform problem focused health histories and physical exams with almost every patient interaction in the primary care setting. This clinical rotation has taught me to be precise and to the point with obtaining a history, performing a focused assessment, and quickly coming up with a diagnosis and treatment plan. In the beginning I found myself going above and beyond with my problem focused history and addressing every single need that the patient wanted to talk about, and then going a complete head to toe assessment of every patient, as my preceptor and I had done in the previous semester. I appreciated my preceptor pointing out that in order to be efficient in the “real” world, you can not address every single problem that the patient tells you about or you will never move on to see all of your patients. I have begun to acknowledge the fact that the patient has many things to talk about but be honest that due to time constraints we should address their top 3 concerns, given that none of the other concerns do not need to be immediately addressed. Patients are very receptive to this method, and it is one that I will continue to use in my future practice.________________________6.Demonstrate diagnostic reasoning and critical thinking □ □ □ □ □ □in the development of a treatment plan60 Hours: Rating between a 3 and 4. Developing a treatment plan is one of the more difficult tasks for me. There are so many appropriate interventions for each diagnosis that it is hard to know what intervention or treatment plan will be most effective although I realize that there are numerous correct interventions for each disease process. I have begun to utilize the Up-to-Date reference in the clinical setting as a quick guide for developing treatment plans. It is my goal to be able to gain independence with the development of my treatment plans. When thinking about diagnostic tests that should be ordered for patients, I have begun to realize the cost associated with many tests including chest xrays, ekgs, and lab draws. My preceptor has helped me in decision making over what tests to order. The first question he said to ask yourself is, what am I looking for with the test? Do I think it would be abnormal? How are my results going to change my treatment plan? For example, we had a patient last week who had an upper respiratory infection for a few weeks with known COPD based off a chest xray that was obtained a month prior. This patient did not have health insurance and was worried about having another one based off of his last bill. On exam, he did not show any clinical signs of congestive heart failure, wheezes were auscultated bilaterally, no crackles heard. He did not have any dependent edema or JVD. Per evidence based practice, This patient needed an antibiotic, long acting bronchodialator, and a 5 day round of prednisone. For this patient we bypassed the chest xray since the treatment plan would not change based off a repeat xray. Another patient that we had was experiencing allergy like symptoms for months without relief, although she has not tried any over the counter medications. Initially, she wanted to undergo allergy testing, when my preceptor agreed was aggressive, but feasible if this is what the patient wanted. After talking to her insurance company, she was going to have to pay $800 out of pocket for the testing alone. From a cost standpoint, she could not afford the testing, and we decided ultimately initial treatment would not change. She was put on a daily allergy medication, Zyrtec, and given an intranasal steroid. A patient was recently seen who had not been to a physician in 15+ years. He presented with shortness of breath with excessive amounts of secretions noted with coughing. He had been having fevers, weight gain, and peripheral edema for 2 months as well. Further diagnostic tests were an important part of this visit since he had not seen a health care provider in so long and if he had any significant health history it was unknown. We obtained a chest xray to assess for pneumonias, tumors, congestive heart failure, an EKG, and lab work that included a CBC to rule out anemia for lethargy and were interested in his WBC as a marker for infection. A TSH was ordered to assess for hypothyroidism with the patients lethargy and weight gain. In this particular patient’s situation, diagnostic tests were going to play a key role in his treatment plan and overall management. 120 Hours: Rating 4On my previous submission, I rated myself between a 3 and a 4. I now feel that I am functioning at a 4 with minimal guidance from my preceptor. I have gained independence in developing a treatment plan, and am improving on my goal of gaining independence with this outcome. Previously, I relied more on my preceptor to guide the treatment plan once I presented my various ideas. Now, he will ask me more questions about why I think a the treatment plan I developed is the best option. I have begun to utilize the evidence based practice tool, Up to date even more than I previously did. This has helped me become much more confident in routine treatment suggestions and provides the support to back my decision for appropriate diagnostic tests.I previously highlighted the importance of making sure that I have a reason why I am performing a diagnostic test. Many of the basic lab tests such as a CBC, CMP, and TSH can be so helpful in ruling in or ruling out a number of a diagnosis. I think that for most patients, it is so important to have a baseline of these values, even from a preventative standpoint. Baseline labs are wonderful to have in order to compare what the patient’s normal values are vs when they are being seen for an acute condition.For example, we had a patient come in who had noticed decreased urine output over the past month. She had not previously been seen in the clinic or by any other healthcare provider, therefore we did not have baseline values to go off of. Her BUN was 22 with a creatinine of 1.4. Her BUN/creatinine ratio was greater than 1:20 therefore she was have prerenal failure. Per literature/EBP, an elevation of serum creatinine greater than 0.5mg/dl above baseline is considered acute renal failure. This was difficult to diagnose based off one set of lab results. The patient appeared to be hypovolemic with low blood pressures, orthostatics obtained, significant drop with lying to sitting and then to standing. Mucous membranes dry. Pt reported that she doesn’t drink water because she doesn’t like it. Encouraged increased water intake, labs to be repeated in one week. If pt doesn’t see improvements she was encouraged to call before one week or go to ED if she worsens for IVF hydration. . My background is as an ICU nurse and when I first started my clinical rotations, I thought that every patient needed a full set of labs along with a chest xray and EKG. I have grown in my thought process and deciding when testing is appropriate.For example, we had a young patient with low back pain who had been seen a week prior. She had remembered going to the gym and doing new exercises a few days prior, before this injury she had not experienccv ed any lower back pain. She was given muscle relaxants and instructed to take 800mg Ibuprofen to help with inflammation. The patient did not report much relief with these interventions, but had not tried any stretching/physical therapy interventions. She said that someone at school suggested an MRI to find out what the underlying problem was. Being a student without health insurance, an MRI would be very costly. The treatment plan that I presented to my preceptor was to continue muscle relaxants and NSAIDs, alternate heat and ice and show her some lower back stretches. If she was interested, we could look into physical therapy options, although they could be expensive without having insurance. Another diagnostic option that came to mind was a spinal xray, although I did not feel this was the best option for her since she did not have a fall, the back pain appeared to be more muscle involvement than skeletal. We agreed on my proposed treatment plan, and she was to follow up in 2 weeks. 180 Hours: Rating between a 4-5I currently rate myself between a 4 and a 5 on this outcome at the end of this clinical experience. I have met my goal of becoming more independent in the development of a treatment plan, therefore feel that this outcome has gone from being one of my weaknesses to one of my strengths. I feel that I have made improvements in being able to utilize critical thinking when analyzing lab values and applying them to various patient situations. Over the last few weeks of clinical, before I present my patient, my preceptor will ask me, so what do you think it is, and what do you think you should do about it? Asking these types of questions has forced me to always come out with my 3-5 differential diagnoses, my top diagnosis, and a treatment plan. I admit, there are times when I haven’t picked the most optimal treatment prior to looking information up, but I think it is an improvement not relying so heavily on preceptor to guide the treatment plan. 7.Initiate screenings appropriate to differential diagnoses □ □ □ □ □ □60 hours: 4Screenings are a part of the secondary level of health promotion. In my current clinical setting, these include but are not limited to lipids screening, diabetes screening, hypertension screening, colonoscopies, and ADHD screening. For most of our adult population, lipid screens are performed routinely for most, whether patients have risk factor dyslipidemia or not. The US Preventative Services Task Force recommends routinely screening men ages 35 and older and women 45 and older for lipid disorders. It is recommended to screen younger as risk factors are identified.We have also initiated these types of lipid screenings in children who are obese, and have identified problems early on through doing this. For example, we had a 12 year old who was 4’10” and 185 pounds. Through screening, he has found to have high triglycerides, low HDL and high LDL. With this child, education about exercise and diet modifications were key to his treatment plan. The screening used in my clinical setting for initial ADHD evaluation is the Conners’ Parent Rating Revised Scale. If patients score greater than a 56, they are considered borderline, and concerns are raised. At this point they are referred on to other health care professionals, usually utilizing Bert Nash in Lawrence for a comprehensive evaluation. With further search regarding ADHD, in order for DSM-IV criteria to be met for ADHD, the following must be present:Behaviors are present in more than one setting, greater than 6 months, be present before age 7, impair function in academic, social or occupational activities, and be excessive for the developmental level of the child.Many patients come in with hypertension in the clinical setting. For further HTN screening, I recommend to all patients that they buy a blood pressure cuff at Walmart or Walgreens and take their blood pressures at home for 2 weeks. To obtain a reading, education is done that the patient should be sitting in a relaxed position for several minutes before obtaining a reading to ensure accuracy. We ask them to bring back their blood pressure log to confirm a diagnosis of HTN. Patients who have blood pressure readings > 130/80 are recommended to do this screening at home. As a general rule of thumb, my preceptor said that he does not diagnose HTN based off of clinic blood pressure readings alone unless readings are significantly high and the patient has numerous risk factors for a cardiovascular event. We have only seen a few patients who had several readings of >160/90 who were placed on HTN medication therapy based off of clinic blood pressure readings alone.It is my goal to be able to rate myself at a 5, which states that I will be consistently and independently recommending screenings to be initiated as they apply to my differential diagnoses. 120 Hours: Rating 4-5I continue to see personal growth when it comes to screenings to help rule in or rule out different diagnoses. Every week that I am in clinic, we see and screen patients for dyslipidemia, diabetes, and HTN. We continue to see a large volume of patients with ADHD. I have become much more comfortable in understanding ADHD treatment. My preceptor usually prefers to refer to Bert Nash for ADHD screening, and he will start or continue ADHD regimens once an official diagnosis is in place. I feel comfortable assessing for side effects of the medications, especially Adderall such as heart palpitations, increased heart rate, and insomnia. Many of these medications carry a high abuse potential, so my preceptor has reinforced the importance of a through interview about how things are going with the medication prior to refilling.180 hours: 5I rate myself at a 5 on this outcome as I am able to independently identify screenings/tests for my differential diagnoses, which was one of my goals for this clinical. I continue to screen for HTN on a daily basis, and now feel that I can appropriately categorize Pre-hypertension, and stages I and II of HTN. Once the diagnosis is made, I am becoming independent with which type of BP medication will be most appropriate for the patient to start on. We start many patients on HCTZ 25mg PO daily. If they have a history of DM, we always start them on an ACEI. There are many combination drug therapies available, but I appreciate my preceptor’s take on prescribing these medications: if you start a combo medication and they have a reaction or do not do well, how do you know which medication they did not tolerate? His philosophy is it is always best to start with one single medication at a time and add on later. I will adopt this thinking to my future practice. Many of the patients that we see with HTN are obese, and most of the type we obtain labs that include a CMP. If the blood glucose is high on a CMP, we add on a HgbA1C. With this patient population, we also screen for dyslipidemia._____8.Initiate diagnostic strategies appropriate to differential □ □ □ □ □ □Diagnoses60 Hours: Rating 4I would rate myself a 4 at this time at being able to initiate/recommend diagnostic testing or strategies for patients with minimal assistance from my preceptor.In outcome 6, I discussed a patient who hadn’t seen a physician for 15 years. His health history was unknown. Based off of his history of present illness, review of systems, and physical exam, I was able to independently formulate a plan of diagnostic strategies that would be important for this patient to rule in or rule out various underlying health problems. With this example, differential diagnosis that I had in my mind prior to collaborating with my preceptor were hypothyroidism, congestive heart failure, pneumonia, COPD, and asthma.120 Hours: Rating 4-5I rate myself at a 4-5 at this time, as I did in outcome 6 and 7. I feel that my explanations in both outcomes show I am initiating diagnostic strategies to help with my differential diagnosis.180 Hours: Rating 5At this time, I feel that I am functioning at a 5 when it comes to initiating/recommending diagnostic strategies for my patients. I continue to think that outcomes 6 and 7 highlight diagnostic strategies, as outcome 6 involves diagnostic reasoning and critical thinking while outcome 7 highlights screening for differential diagnoses. I have given numerous examples of the incorporation of diagnostic strategies when explaining different patient scenarios. I recently had a patient who originally presented with contact dermatitis bilaterally on arms and trunk. After discussing his dermatologic issue, he brought up that he has been unable to lose weight despite working out with a physical trainer 3 days a week and doing 30+ minutes of cardio exercise the other days. The patient reports intermittent chest pain with exercise. None today. He eats a well-balanced diet. I recommended that we obtain a baseline EKG. The patient is significantly overweight, so I asked if he had ever had an exercise stress test. The American Association of Cardiology and American Heart Association formed to make recommendations for stress testing in individuals with known or suspected cardiovascular disease. This patient met this criteria based on a familial history of heart disease and intermittent chest pain with aerobic exercise. I also suggested checking a TSH to check for hypothyroidism and a CBC/CMP/Lipid panel since patient had not had lab tests in a few years. ______________________________________________________________________________9. Develop a plan of care utilizing evidence-based practice □ □ □ □ □ □60 Hours: Rating between a 3-4Evidence Based Practice Guidelines exist for virtually all disease processes and diagnoses. To access evidence based practice guidelines, I am currently using the Up-To-Date electronic reference database. This provides a quick reference to what is currently recommended in the clinical setting. I also use the ADA guidelines for diabetes management as well as the American Heart Association guidelines for HTN management. I would rate myself a 3-4 as many times I ask questions about guidelines and implementation in the primary care setting. Many times, I need to look up evidence based guideline before I can formulate a treatment plan to include diagnostic strategies. It is my goal to be able to quickly access evidence-based practice guidelines as they apply in the clinical setting, as I recognize that it is not a feasible to goal to memorize all of the most up to date guidelines and evidence based practices.120 Hours: 4 I continue to utilize the electronic reference Up to Date very much in my clinical setting. It is a very quick reference for me, easy to read and understand. This site has helped familiarize me and helped me gain confidence with basic guidelines, much as I highlighted after 60 hours of clinical time. Evidence based practice is always changing and I think it is important to have a source is reliable and user friendly. I have gained independence with developing a plan for the patients that we see. Guidelines for HTN, DM, Dyslipidemia are pretty straight forward to understand, although I realize there are grey areas in every diagnosis where multiple treatment plans are acceptable.180 hours: 4.5-5I have gained speed and efficiency in electronically accessing evidence based practice guidelines, therefore have met the goal I set at 60 hours. Once I have accessed evidence based practice guidelines, I feel that I can accurately and independently develop a plan of care that will be most suitable for the patient. Throughout my entire CPT, I have given examples of how I have incorporated evidence based practice into the clinical setting.__________________10. Prescribe medications based on cost, diagnoses, □ □ □ □ □ □efficacy, safety, and individual patient needs60 Hours: Rating 3At this time, I would rate myself a 3 in this area as I have begun to integrate evidence based practice guidelines into my clinical treatment plan. It is important to consider whether the patient has health insurance or not. I have familiarized myself with the $4 medication list when recommending pharmacology interventions for patients. Patients who are able to afford their prescriptions are more likely to be adherent to their medication regimen and control their underlying medical problems. For example, we had a new patient who was being seen for HTN. The previous provider placed him on a combination medication that was not fully covered by his insurance, costing him around $50 a month out of pocket. The patient came in and his blood pressure was 170s/100s. He said that due to the cost of his old medication, he decided not to take it and hope that his blood pressure would just get better. This patient required education over the importance that blood pressure medications and lifestyle modifications play in the management of HTN. He was place on HCTZ and Amlodipine, both medications off the $4 list. The patient said that he would be able to adhere to his medication regimen with spending $8 a month on these medications.Each patient has individual needs for managing their health conditions. For example, we had a patient with high triglycerides and total cholesterol. His previous health care provider placed him on a statin, which the patient said was “un-necessary”. He was interested in a more holistic approach for his disease management. Since he did not want to take his statin, we started him on Fish Oil 4,000mg a day and discussed dietary modifications to help him achieve get his triglycerides and cholesterol in range.I recognize that I need to gain independence in developing a treatment plan that includes what type of medication to start patients on. I still feel that this is an area of weakness for me.120 Hours: Rating 4I continue to rate myself at a 4 as I do not feel that I am at the completely independent when choosing medications to prescribe, although I usually have several medications in mind, when discussing my treatment plan with my preceptor. I see room for personal improvement when deciding: Antibiotics vs symptomatic treatment for URI like symptoms. I feel that in the both of the clinical settings I have been in, my preceptors will decide to prescribe Antibiotics when we diagnose what appears to be a viral URI. They have both told me that you learn to read your patient. If they are set on the fact that they need an antibiotic, often times it is appropriate to go ahead and put them on one. With so many drug resistant strains to antibiotic therapy, I am trying to gain a better understanding to this particular concept.I continue to take into consideration generic vs brand medications and better understand prescription insurance and what medications will cost a patient. I have really come to appreciate the drug representatives that come to the clinic. It is wonderful how they can quickly give you practice pearls for each medication as well as samples with prescription assistance cards. They are great about letting you know how different insurance companies will cover medications, and how different patient conditions need to be billed for in order for reimbursement. 180 Hours: Rating 5Since my first submission, I have completed 120 additional clinical hours which have helped me to achieve the goal I set of gaining independence with prescribing medications based on cost, the patient’s diagnosis, safety, and individual needs. My preceptor has really pushed me in developing a treatment plan that includes appropriate medication prescribing for the patient. Cost of medications is a huge concern for many patients, and taking this into consideration can play a key role in medication compliance. The electronic ordering that my clinical site uses is very helpful in that it highlights $4 medications for you so that you know right off hand if you are prescribing something that will be inexpensive for the patient. I utilize Up to Date numerous times throughout the day to ensure that the medication I am choosing is the one most indicated based on the diagnoses and patient presentation. I have learned to alter my medication choice based on how many times a day the medication needs to be taken. For example, for many people, it would be very difficult for them to remember to take an antibiotic four times a day for a week, therefore I chose a daily for twice daily antibiotic for compliance. ______________________________________________________________________________11. Perform medical and surgical procedures as appropriate □ □ □ □ □60 Hours: Rating 0 for surgical procedures, 4 with medical proceduresAt this point, I have not had the opportunity to perform surgical procedures in the my clinical setting. My preceptor said that the practice does not perform many in office procedures. Most patients who need surgical type procedures are referred on to specialists. As far as medical procedures, I have performed several breast exams and pelvic exams with minimal assistance from my preceptor. With a pelvic exam, I am able to find the cervix in most patients and my preceptor will look over my shoulder to double check what I am seeing. I have discussed wanting to be involved in as many medical procedures and exams as possible with my preceptor and am optimistic for future opportunities.120 Hours: 3-4 At my clinical site, we do not perform very many surgical procedures. I had the opportunity to aspirate fluid from a patient with olecranon bursitis. My preceptor talked me through the procedure before entering the room, I maintained a sterile field and successfully independently aspirated fluid. The fluid was sent for culture.I assisted in draining and packing an abscess on a patient’s back. A culture and sensitivity of abscess contents was sent. The wound was packed with sterile packing and the patient was instructed to return 3 times a week to repack. The patient was also placed on Keflex 500mg PO BID x7 days to cover for infection.I continue to perform at least one pelvic exam on a weekly basis and do so with minimal assistance. 180 Hours: 4Throughout this clinical experience, I have had minimal exposure to a variety of medical or surgical procedures. I performed many well woman pelvic exams independently with minimal assistance from my preceptor. I find it difficult to accurately rate myself on surgical procedures since they only opportunity that presented as for the bursitis aspiration and a recent tunneling wound packing. I recognize that these are areas of weakness and it is my goal to obtain as many of these opportunities as possible in my next clinical rotation. I felt that it was out of my control to see much growth and improvement on this outcome when the opportunity rarely presented. 12.Interpret patient responses to treatment and recommend □ □ □ □ □ □changes to the treatment plan as indicated60 Hours: Rating 3I would rate myself between a 3 on this outcome right now because I often rely on my preceptor to make clinical decisions based on patient responses for treatment, which I recognize is a weakness. For example, we had a patient following up for HTN. She was started on HCTZ and blood pressures will still borderline, on CMP her potassium was stable. I had two treatment plans for this patient. One was to increase her HCTZ to 50mg daily or to stay on 25 and add an Ace inhibitor since she was also newly diagnosed with DM type 2. While both treatment options were acceptable, we chose to add Lisinopril because evidence shows that patients with diabetes benefit from ace inhibitors. I have seen personal growth from last semester at analyzing lab values such as a TSH or lipid profile and making recommendations for treatment plan changes. However, it is my goal to be functioning at a 4 or a 5 by the time that this clinical rotation is complete. 120 Hours; Rating 4At this point, I am functioning at a level 4. The patient responses to treatment that I am most familiar with at this point is vital sign changes/responses and lab changes. When starting patient on HTN meds or dyslipidemia meds, baseline labs are obtained (as part of the differential process) Following up in 2-4 weeks is standard at my clinical site to monitor a patient’s response to treatment. I have gained comfort with developing individualized plans/ changes/responses to treatment. 180 Hours: Rating 4-5I rate myself between a 4 and a 5 on this outcome as I am able to interpret if a patient is responding to medication or treatment independently most of the time, although there are instances where I need clarification and help from my preceptor. Before interacting with the patient, I always review the chart and the last visit or two if they are an established patient. I also look at the vital signs that the nurse obtained while rooming the patient. This gives me the opportunity to identify both acute and chronic health problems, current medications, previous medication changes, and the most recent labs that were drawn. From gathering this data, I can usually determine the effectiveness of the treatment intervention and suggest changes to therapy.____________________________________13.Document using professional terminology, □ □ □ □ □ □format and technology (ie: ICD9, E/M coding, CPT)60 Hours: Rating 4At this time I would rate myself at a 4; routinely meeting expectations with minimal support from my preceptor. In my Adult Health I clinical I did not have the opportunity to officially document. This semester at Mt. Oread I am able to document on most patients that I see and do so with some help from my preceptor. It is my goal to independently cart by the end of the clinical rotation. He has given me positive feedback about my documentation and has given me some very helpful pointers of things to include in my notes. I have also gained confidence as far as official ICD 9 diagnosis and CPT coding. I am familiar with proper coding for reimbursement of diagnostics such as a chest xray being shortness of air or for reimbursement for a Urine Dipstick/culture being dysuria. Proper coding and billing is a crucial part of the job as an ARNP.120 Hours: Rating 4.5I rate myself at a 4.5 at this point. In my clinical setting, I am able to independently document although on some patients I do need assistance with wording to help my documentation flow nicely. I feel that I am thorough and include necessary components to documentation. I do appreciate feedback and suggestions to improve charting. I am able to chose appropriate CPT coding based on the level of the visit as well assign ICD 9 codes to each diagnosis.When it comes to my documentation in the hospital setting, I would rate myself a 3-4, as I am not completely comfortable with the complexity of the electronic documentation program, as it is a varied version from the clinic I am in. I required more guidance in the documentation process in this setting, but will have a few more opportunities in the hospital setting for personal growth. 180 Hours: Rating 5I consistently document using professional terminology. I have become proficient charting electronically at the clinic. By the end of 180 hours, I was able to completely chart as I went and stay caught up on everything. I was able to see approximately 3 patients an hour including documentation, which I think is one of my strengths this semester and met my goal of becoming independent with documentation by the end of the semester. During my 120 hour log, I discussed a goal of improved efficiency with documentation in the hospital setting. I felt I met this goal during my last 2 days in that setting. I was able to documented updates on patients almost independently and document on new admissions with minimal assistance.______________________________________________________________________________14. Recognize need for referrals by collaborating □ □ □ □ □ □and consulting with members of the health care team120 Hours Rating: 5In my clinical setting, many of the patients that we care for are being managed from multiple aspects of the medical field. For example, some of the diabetic patients that we care for are not able to be controlled by the primary care clinic interventions. They are then sent on for further management with endocrinology. I appreciate my preceptor’s perspective on family medicine: You have to know the basics about everything. When it gets more complicated, leave it to the experts. They will better manage the patient or help you in providing better care for your patients. Most of our chronic pain patients are referred to pain management. This group of professionals have an extensive knowledge of various treatment options that are most effective in managing this challenging population.I appreciate the collaborative approach that I see with the clinicians at my clinical site. Each provider has an area of “expertise” within the clinic. For example, many of the physicians refer their patients to my preceptor since he performs colonoscopies. The women’s health patients we see that are interested in an IUD or Implanon are referred to one of the two female providers who have a better knowledge base of these procedures. Being able to come together and collaborate as a team is going to be crucial to my future practiceWhen I was in the hospital setting, I was able to witness collaboration between the Nurse Practitioner with Physicians, nurses, dietary, PT, and pharmacy. 180 Hours: Rating 5As a Nurse Practitioner, it will be very important to consult and have a good working relationship with my collaborating physician. I understand that there will be situations that are out of my comfort zone that I need to collaborate or refer on. I recognize the need for referrals, consults, and collaboration daily.______________________________________________________________________________15. Discuss access, cost, efficacy and quality when □ □ □ □ □ □making care decisions120 Hours: Rating 5I rate myself at a 5 when it comes to assisting patients in receiving the most optimal health care that takes into consideration cost and quality. As part of Elogs, we look up insurance information on patients. I take into consideration what type of insurance patients have when developing a plan of care.180 Hours: Rating 5I continue to rate myself at a 5. As previously mentioned, I look at what type of insurance patients have prior to interactions. Over the past year, I have become more aware at the price of lab and diagnostic tests. For example, we recently had a patient who was 2 weeks away from having insurance who presented in the clinic with a URI and was placed on antibiotics. The patient was obese with an elevated blood pressure with a systolic blood pressure in the 140s and systolic in the 90s. He mentioned wanting to be checked for diabetes. When discussing his case with my preceptor, we agreed that further testing today did not need to be done. He would have insurance to cover the lab tests and further diagnostics in 2 weeks, therefore it would be more cost effective to the patient if he waited. ________________________________________________________________________16. Perform care in a timely manner □ □ □ □ □ □120 Hours: Rating 4I currently function at a 4 when it comes to performing care in a timely manner. I can usually independently see clinic patients in approximately 15 minutes. During this time, I am able to document Subjective, HPI, ROS, and sometimes physical examination findings. I then go out and discuss the patient with my preceptor and fill out the plan when I leave the room. It is my goal to be able to complete this in 10 minutes by the end of 180 hours.180 Hours: Rating 5I rate myself a 5 on this outcome, as I have become more efficient since my 120 hour submission, therefore met my goal. For most patients, I am able to complete a problem focused history and complete an exam in approximately 10 minutes. I know that this is not a realistic goal for me with well visits for new patient visits that require a more in depth history taking process and examination. I have also been able to provide care in a more timely manner as I have gained speed and efficiency utilizing electronic references to look information up and apply it to different patient situations.______________________________________________________________________________17. Maintain confidentiality and privacy □ □ □ □ □ □120 Hours: Rating 5I always maintain patient confidentiality and privacy whether it be at the clinic or hospital. 180 Hours: Rating 5I continue to rate myself at a 5 as I continue to respect and maintain privacy and confidentiality.______________________________________________________________________________18.Demonstrate professional behavior □ □ □ □ □ □120 & 180 Hours: Rating 5 I would give myself a 5 when it comes to professional behavior. I am always respectful and represent Washburn University anytime I am in the clinical setting.______________________________________________________________________________20. Employ effective communication methods with patients, □ □ □ □ □ □families, preceptor, and staff120 & 180 Hours: I feel that I display effective clear communication skills in every aspect of my clinical. I ask questions of my preceptor when I am unsure of care and respect any feedback or constructive criticism that he has to offer. ______________________________________________________________________________21. Provide culturally competent care to patients □ □ □ □ □ □and families and negotiates a mutually acceptableplan of care120 Hours: I rate myself a 5 on this outcome, as I provide culturally sensitive care. To me, culturally sensitive care is not just being aware of other ethnicities and their beliefs, but to be aware of different socioeconomic statuses. Socioeconomics play a key role in developing effective plans of care for each individual patient.For patients who do not speak English, interpretation services are available. I always try to make sure that I am speaking to the patient and not the interpreter and makes sure that all of the patients needs are addressed and that they understand their plan of care.22. Communicate practice knowledge effectively both □ □ □ □ □ □orally and in writing120 Hours: Rating 4-5I currently rate myself a 4-5 on this outcome. I demonstrate communicating practice knowledge with the electronic documentation at my clinical site. For the most part, I am independent in almost all aspects of the documentation process, although I always discuss all of my findings with my preceptor prior to charting. I communicate practice knowledge effectively through patient presentations. I rate myself more at a 4 as far as oral communication with patient presentations. I am independent, yet require some guidance. I realize that this is an area that I need to improve on, but have seen personal growth over this past semester. Sometimes I find it difficult to give a complete presentation in 2-3 minutes, which is generally the time frame that my preceptor has encouraged me to present in.180 Hours: Rating 5I rate myself at a 5 as I have seen improvements since my 120 hour submission with orally communicating patient presentations to my preceptor. I consistently communicate in writing through patient documentation. I have received positive feedback from my preceptor regarding my progress in this area.______________________________________________________________________________23. Apply available evidence to continuously □ □ □ □ □ □improve quality clinical practice120 & 180 Hours: I rate myself at a 5 on this outcomes, as I am continuously looking up evidence based guidelines in order to provide the most up to date practice standards. I have become accustomed to using Up to Date to look up practice guidelines. The information on Up to Date is all Evidence Based Practice. The site is very user friendly as it is easy to navigate and gives clear precise information. ______________________________________________________________________________24. Utilize appropriate agency educational tools □ □ □ □ □ □to provide effective, personalized health care topatients and caregivers120 & 180 Hours: I rate myself at a 5 on providing education tools for patients. The clinical site I am at does many well child visits. The clinic has brief handouts to give to parents/guardians for each age group, newborn 1-2 months, 3-4 months, 6, 9, 12 months and then each year after that. This is a great tool to provide education about what to expect as far as developmental milestones, sleeping, eating, etc. Other educational tools that we have available are drug information that can be printed off of Up to date that briefly highlights key information for patients to understand about their medications. This is a great reinforcement in addition to verbal education. ______________________________________________________________________________25. Coach the patient and caregiver for positive □ □ □ □ □ □behavioral change120 Hours: Rating 5 I currently operate at a 5 on this outcome. Most patient interactions present the opportunity for primary and secondary levels of prevention. With every patient, smoking or tobacco use is brought up whether it is known if they have a history or not. For patients who don’t smoke, we always tell them how positive it is for their health that they don’t. For patients who do smoke, smoking cessation is highly stressed and encouraged with every single interaction. If they are at the point that they are ready to quit, we discuss various options for cessation. If patients report that they are not ready to quit, they are encouraged to call or come back if they change their mind. Many patients benefit from encouraging behavioral change in the form of nutritional improvements. By patients losing weight, they will overall feel better, and may reduce the incidence of DM, hypertension, dyslipidemia as well as many other co morbities. 180 Hours: I continue to encourage positive behavioral change for all patients. I have had numerous opportunities over the past semester to encourage weight loss through healthy eating habits and exercise. Evidence based practice has shown that a 5-7% goal for weight loss is the most realistic, and when people set goals of 30% total weight loss or more they are less likely to succeed. Smoking cessation continues to be a behavioral change that I encourage daily with many patients in the clinic. ______________________________________________________________________________26. Demonstrate information literacy skills in complex □ □ □ □ □ □ decision making120 & 180 Hours: I currently rate myself between a 4 and 5 for this outcome. I am able to use the practice foundation of knowledge that I have thus far in school and use it to make decisions in the clinical setting. I am able to research and have an understanding of various diagnosis, medications, and treatment options. Although I feel I am mostly independent with this outcome, I still like to go through my findings with my preceptor and discuss various ways that he makes decisions involving patient care.______________________________________________________________________________27. Integrate ethical principles in decision making □ □ □ □ □ □120 & 180 Hours: I make ethically sound decisions in all aspects of my clinical practice, therefore rate myself at a 5. I take into consideration the principles of beneficence, non-maleficence and justice. I always strive to provide the most beneficial care to my patients that will do no harm. The principle of justice plays a key role in decision making as patients have the right to be informed and interactive in developing their individualized plan of care.28. Demonstrate respect, compassion and integrity □ □ □ □ □ □120 & 180 Hours: I rate myself at a 5 on this outcome, as I always treat each patient with kindness, compassion, respect and integrity.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____Krystal Morris (electronic signature) Date: 2/13/12Faculty Signature______________________________________Date____________________Submission #2 after 120 hours of practicumStudent Signature: Krystal MorrisDate 3/18/12Faculty Signature_____________________________________Date____________________Final SubmissionStudent Signature: Krystal Morris Date: 4/22/2012Faculty Signature____________________________________Date____________________Faculty Comments/Final Grade:November, 2011Revised 1/23/12 ................
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