NURS601B APRN Bridge course All Weeks Assignment
Week 4 Assignment
Meaningful Use for Nurses Paper
You will select (2) Core objectives to enable EHRs to support healthcare from Stage 1. You will select (2) Menu objectives that provide flexibility for providers to choose from Stage 1 or Stage 2.
Table 17-1 (Sewell text, chapter 17-1, p. 274).
To earn full credit, your paper must include the following components:
A. Introduction and overview of the Meaningful Use Program – provide an overview of the Meaningful Use Program. Describe its significance to advanced practice registered nursing and the impact it has on the nursing profession.
What is it?
When did it originate? Why is it needed?
What are the relationships between EMR, EHR, and ePHR to clinical information systems?
What is the significance to the nursing profession, especially to the PCP?
B. Discussion and analysis of the Meaningful Use Program (MUP) – describe and analyze the goals and objectives of meaningful use as well as its implications for nurses, nursing, national health policy, patient outcomes, and population health associated with the collection and use of meaningful use core criteria.
Review the goals and objectives and discuss them. Is this something you see or deal with in your workplace?
Discuss the implications – is the program effective? Is it affordable? Does it work? Does it really improve quality and efficiency of care?
What are the strengths and weaknesses of MUP?
Support your ideas with evidence-based practice.
C. Core Requirements of the Meaningful Use Program – analyze how the core requirements are beneficial for advanced nurses, nursing, monitoring population health, setting national health policies, and/or improvements in patient outcomes or population health.
Patients – discuss impact of MUP on the use of patient reminders, ePrescribing, electronic access, etc.
Providers – does MUP assist providers in making more informed decisions, deliver better care, and create greater efficiencies?
Nursing – does MUP help to prevent duplicative testing, eliminate adverse drug reactions, and enhance provider collaboration?
Population health – does MUP encourage providers to send data to immunization registries and public health agencies?
D. Challenges and recommendations – discuss current challenges with meaningful use seen in practice today and provide recommendations using evidence-based rationale.
Challenges – lack of clear plan, cost, lack of oversight, privacy risks, concerns about sustainability
Recommendations – realistic, scalable, and flexible starting point for adopting EHR, allow reasonable time for robust EHR use, ensure adequate training, better communication with physicians and providers
E. Conclusion – summarize your findings and conclude by providing insights gained from your analysis.
Do not introduce new concepts
Summarize the highlights of your findings
Offer your insights
A minimum of 2 scholarly resources are required not including your texts.
Your paper should be 2-3 pages, not including title and reference pages.
Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.
NURS601B APRN Bridge course
Week 7 Assignment
Comprehensive H&P Case Study
The purpose of this paper is to understand the importance of accurate medical record documentation to record pertinent facts, findings, and observations about a patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
Directions:
Step 1:
Review and critique the comprehensive H&P and thoroughly answer the questions that follow in complete sentences and paragraphs using question and answer APA format.
Step 2:
Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.
Step 3:
Keep in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by CMS. Visit CMS.gov, and then search “1997 Guidelines of Documentation for Evaluation and Management” for information that should be included in a medical record.
Answer the following questions:
1. Does this document meet the CMS guidelines for documentation of a comprehensive history and physical? Why or why not? Be specific.
2. Critically analyze the H&P and list any errors. Identify the strengths of the H&P.
3. Did any questions come to mind that you are unable to answer after reading the H&P?
4. Are the conditions listed in the assessment section reasonably supported by the history? Why or why not? Explain your rationale.
5. Did you identify other differential diagnoses or conditions that should be included in the assessment? If so, list them.
6. List the ICD-10 code for each of the following (go to CMS.gov and search for the ICD-10 Codes):
Moderate persistent asthma with (acute) exacerbation: ______________
Pneumonia, unspecified organism: ______________
Essential (primary) hypertension: ______________
Hyperlipidemia, unspecified ______________
Obesity: ______________
7. Is it appropriate to include the ICD-10 code for pneumonia when billing for this visit? Why or why not?
8. Is the plan reasonable based on the assessments listed? Why or why not?
9. List 3 patient education strategies relevant to the case study including specific medication teaching. Include references.
10. List health promotion recommendations from AHRQ according to age/gender/conditions. Cite your references.
Your paper should be 2-3 pages not including the title and reference pages. A minimum of 2 sources, not including your texts, must be incorporated into your paper.
Use current APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. Include a title page and a reference page listing the sources you used.
601B Comprehensive H&P guidelines.docx
A comprehensive H&P for patient Anne Smith is shown. Ms. Smith is a new patient presenting to an internal medicine office-based practice. Carly Sanders, an experienced nurse practitioner, authored the H&P.
Patient Name: Anne Smith Age: 55
Date of Visit: 2-14-2016 Gender: Female
Information Source: Patient, reliable source, face-to-face office visit
Subjective:
Chief Complaint: Follow up after Emergency Department visit
History of Present Illness: Reports were seen in the Emergency Department approximately 2 weeks ago and was treated for bronchitis with an unknown antibiotic that she has now finished. Was prescribed a refill of an Albuterol MDI as well. Pt continues to report cough and shortness of breath with exertion. Cough and shortness of breath have not improved since last Emergency Room visit. Cough reported as dry and present day and night without provocation. Has been using Albuterol MDI 4–5 times per day with slight relief of shortness of breath symptoms. Pt reports multiple diagnoses of bronchitis last year and has been using Albuterol MDI multiple times daily for the past 6 months or more.
PMH: Hypertension. Bronchitis. Hyperlipidemia. Obesity.
Medications: HTCZ 25mg BID. Albuterol MDI q4h PRN. Simvastatin 20mg daily. OTC Aleve 1–2 tabs PRN headaches.
Allergies: Codeine. Shellfish.
Family History: Mother and Father with CV disease. Son with asthma. Daughter with hypertension. Denies family history of DM. Mother diagnosed with breast cancer at age 40, died at 44.
Social History: Retired from clerical work. Widowed. Lives with adult children and assists with watching grandchildren. Denies tobacco use, ETOH use, drug use.
Review of Systems:
GENERAL: Reports good sleep but decreased energy levels. Denies fever.
CV: (-) palpitations. (-) CP. (-) swelling.
PULM: (+) SOB with exertion. (+) wheezing. (+) dry cough. (-) hemoptysis.
ENT: (-) rhinorrhea. (-) sinus pain/pressure. (-) ear pain/pressure. (-) sore throat.
Objective:
CV: RRR, no murmur.
Pulm : Posterior inspiratory wheezes bilaterally in all lobes. No rales/rhonchi/crackles. No consolidation present with percussion. Equal rise and fall of chest. No accessory muscle use.
Ears: Bilat TM pearly white, canals clear, no discharge, no external ear tenderness.
Nose: Nasal mucosa pink, moist. No discharge present. No sinus pressure pain.
Throat/Neck: Oral mucosa pink/moist. Tonsils grade 1 without exudate. No lymphadenopathy.
General: Obese caucasian female. Affect appropriate. Appears very anxious. Appropriately dressed. No obvious deformity.
VS: Temp 97.8, Pulse 72 RR 22, BP 140/90, BMI 32
Assessment:
1. Moderate persistent asthma with (acute) exacerbation
2. Pneumonia, unspecified organism
3. Essential (primary) hypertension
4. Hyperlipidemia, unspecified
5. Obesity
Plan:
Dx Plan: None
Tx Plan: Rx: Qvar 40mcg/spray 2 puffs BID. Rx: Albuterol MDI 1-2puffs q4h PRN wheezing. Rx: Inhalation Spacer Device. Refill HTCZ 25mg PO BID #30 with 2 refills.
Refill Simvastatin 20mg PO QD #30 with 2 refills.