NR 511 Week 8 Documenting Clinical Encounters MyEvaluationsStudent Standards

$15.00

Institution	NR 511 Differential Diagnosis and Primary Care Practicum
Contributor	Henali

Description

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