Walden University NURS 6550 iHuman Suggestions LATEST 2021iHuman Suggestions
1. The most important part of any note is the HPI. It should include
... [Show More] identifiers, pertinent past history, and address the chief complaint including; timing, onset, duration, consistency, location, relieving factors, aggravating factors, etc.. a. This is essential for at least two reasons: to provide communication for patient care and for billing. Look at the Medicare guidelines for billing specific notes. You must have at least 4-5 qualifiers and demonstrate high level thinking (plan is included here).
2. Here is an example from a cardiology patient: a. “This 65-year-old Caucasian male with a past medical history of coronary artery disease, hypertension, hyperlipidemia, T2DM (last A1c 6.8%) and obstructive sleep apnea (uses CPAP nightly) is seen in the ED in consultation for chest pain. His previous cardiac history includes drug-eluding stents to the right coronary artery (2.75mm x 12mm) and left anterior descending (3.0x18mm) both on 5/9/2014. His last known ejection fraction was 55-60% on 6/8/2015. He has no recent stress testing. He presented to the ED today after 30 minutes of chest pain. This occurred while resting, was severe in intensity, substernal, radiating to his jaw and down his left arm, associated with dyspnea and diaphoresis, and relieved with 3 sublingual nitroglycerin tablets. He is currently pain free. He has not experienced any exertional chest pain over the past 2-3 months. He is currently pain free. ECG is negative for ST-T changes. Troponin is 0.25 on admission.”
b. This is a fictional patient but you can get a clear picture of why he is there and his pertinent cardiac history. It is short but packed with information.
3. Work slowly through the history and ask good questions. The most important skill your will have as a ANP is history taking. You will experience this when you spend an hour with a patient, only to have someone skilled come behind you and learn more in 2 minutes than you did in an hour. iHuman will help you develop this skill in a very safe and controlled environment. Truth #1 of advanced practice – “the eyes can’t see and the ears can’t hear what the mind doesn’t know”! a. You will need to research what questions you need to ask to be successful with patients out of your comfort zone.
4. Cast a very wide net with your differential diagnosis. There are “can’t miss” diagnosis living in all areas. You will need to figure out what these are. Again, ask questions! Ask your preceptor “what are the not miss diagnosis with ????”.
5. PLAN: this gets complicated, but needs to be simple. When you are working, start reading H&Ps differently and critically. 10 pages or orders are ridiculous and will not be read, leading to errors. Orders should read: a. Admit to ??? (your biggest decision is where) with a diagnosis of ?????. b. Then the housekeeping begins. i. Consult
ii. Procedures
iii. Labs iv. Diagnostics v. Medications
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