NR 511 Week 8 Documenting Clinical Encounters MyEvaluationsStudent Standards
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| Institution | NR 511 Differential Diagnosis and Primary Care Practicum |
| Contributor | Henali |
Documenting Clinical Encounters
MyEvaluations Student Standards
PATIENT INFO
Patient Initials Gender Age range Ethnicity
VISIT INFO
Minutes
Record the number of minutes that the encounter took including reviewing chart, history, physical exam, presentation to preceptor, development of plan, communicating plan to patient and any documentation that you do in the patient’s chart. *Note the number of patients you should be seeing per hour in each course clinical grading rubric in week 8.
*Note that you cannot chart one patient an hour and count that as clinical time. For example, if you chart 12 patients for one day, but were only in clinic 8 hours, the12 patients do not count as 12 hours.
Client Complexity
- Comfort Assessment-will rarely use; actually not sure when this would be appropriate other than in a hospice setting or if managing a patient that is dying
- Episodic (acute condition)-common for sick visits or acute problems; usually not scheduled in advance
- Single/controlled/chronic disease-one chronic disease that is well-managed, such as providing a refill for anti-HTN meds when BP is well controlled
- Single/uncontrolled/chronic disease-management of one chronic disease that is not well controlled, such as intervention (labs, medication adjustment, etc.) for poorly controlled HTN.
- Multiple/controlled/chronic diseases-management of more than one chronic condition that is well controlled (asthma, COPD, DM, HTN, allergies, etc.)
- Multiple/uncontrolled/chronic diseases-management of more than one chronic condition that is not well controlled (same examples but require more the conditions require more work-up or intervention than if they were controlled).............................. Continue
| Instituition / Term | |
| Term | Year 2022 |
| Institution | NR 511 Differential Diagnosis and Primary Care Practicum |
| Contributor | Henali |
