Assessment includes long-term (current) use of opiate analgesic, myalgia, cervicalgia, chronic pain due to trauma and headache.…
For each nursing diagnosis, state two desired outcomes using NOC criteria. Desired outcomes must be patient-centered and measurable within an identified timeframe.…
When entering past medical history and Review of Systems into the EHR system, it can be helpful to nurses and physicians due to it auto-populating within the documentation. With this occurring in the EHR the physicians tend to only address the abnormal findings within the assessment / treatment. In other ways it is not helpful to nurses an example is “a patient stated she had a hysterectomy and when the nurse goes to type in in a template pops-up and ask what kind of hysterectomy and unless you know specifically it is difficult to choose due to it having a code attached to it.…
Electronic health records (EHR) are often confused in terminology with electronic medical records and the two are vastly different with only a few similarities. Electronic medical records are the culmination of medical information of patients in one office. Electronic health records are designed to follow the patient wherever they receive care to build a complete history of care, treatment, and diagnoses to allow accurate care. EHR’s design is to be shared with any provider, health care system or organization, and ancillary provider to easily share the patient’s health history. This culmination of information follows the patient to any facility in town, in the state, or in the country to provide the most effective history on the…
The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician 's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. (HIMSS)…
The staff employed in a medical facility depends on many things to keep the quality of patient care in the positive and efficient. Physicians and nursing need the current and most recent information on a patient to ensure this. The EHR system makes this more possible because the rate for exchange of information increases with this system. It not only provides more accessibility to a patient records from the other facilities and departments that also carry their medical information, but can also ensure the patient will get the best care possible by keeping the staff up to date with their medical information using these coordinating methods. Some of these methods include information such as diagnostic reports where they can be uploaded into the system instantly once complete and offer a faster rate of review for the staff. Did I mention that this system also notifies the assisting staff when these reports are ready for review? Imagine how many live could be saved or changed with this? (Dickerson, Sensmeier, 2010).…
An electronic health record (EHR) defines as the permissible patient record created in hospitals that serve as the data source for all health records. It is an electronic version of a paper chart that includes the patient’s medical history, maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care. Information that is readily available includes information such as demographics, progress notes, allergies, medications, vital signs, past medical history, immunizations, laboratory data, & radiology reports. The intent of an EHR can be understood as a complete record of patient encounters. It also allows for the automation and streamlining of the workflow on health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting. There are many functions associated with patient health records. Not only is the record used to document patient care, but the record is also used for financial, legal information, research, and quality improvement purposes. The integration of technology and health care will enable health professionals to provide more effective quality care.…
In recent years electronic health records (EHR) has evolved its concept as a systematic collection of electronic health information about patients or populations. While most hospitals continue to you paper-based records others seem to be jumping on the bandwagon. Currently the US is lagging behind other countries that use EHR. The research paper compares the effectiveness and efficient of EHR over paper-based.…
"Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (Merskey & Bogduk, 1994). According to Liebeskind (1991), pain is a universal phenomenon that can have a detrimental effect on mobility, sleeping and eating patterns, personal relationships, immune system, overall functional status and psychological well-being, and it has also been the most common reason for medical appointments. Pain is a complex, multidimensional perception that varies in quality, duration and strength (McGrath, 1994). Pain is a subjective symptom that cannot be objectively measured in the way that blood pressure or heart rate can be measured (Strong, Unruh, Wright, & Baxter, 2002). The definition of pain highlights the duality of pain experience and suggests that the perception of pain and how a person report pain is influenced by physiological and psychological factors; however, our understanding of pain and how it perceived by different people is still limited and more research need to be conducted in this field since pain evaluation and pain relief are important goals for the health care providers and clients.…
References: burdens, chronic pain is a burden to the healthcare system (Opsina & Harstall, 2002).…
1. Assess the patient level of consciousness, the positioning of limb and spine ,site where the pain is experienced…
The concepts of this theory are the balance between analgesia and side effects, pain, and side effects themselves. Opioid analgesics often have very unpleasant side effects, so the end result is often patients taking less medication than they actually need, which results in pain not being effectively relieved. The combination of potent analgesics, pharmacological and non-pharmacological adjuvants can allow for the pain relief needed and also help minimize or eliminate unwanted side effects. Nurses can work with the patient to educate them on the side effects of potent medication and help them set realistic goals. This will entail working with both the patient and physician to achieve the results desired.…
Pain management is a major concern for nursing care. Not only does controlling pain help the patient rest and heal, it also improves patient satisfaction. Pain management involves more than providing the patient with pain medication, it is an entire nursing process that starts at the time of admission. “A thorough pain history and shared goal setting are critical components of effective pain management that leads to beneficial outcomes” (Glowacki, 2015). Pain history includes past experiences of pain, current and past pain methods that have managed pain effectively, a tolerable level of pain, triggers of pain, and so on. Obtaining this history is imperative for the nurse in order to meet the patient’s pain management goals. This may just be…
No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished. Although pain is a common experience among individuals 65 years of age and older, it is not a normal process of aging. Pain indicates pathology or injury. Pain should never be considered something to tolerate or accept in one's later years.…
Herr, K. Decker, S. (2010). Assessment of the Abbey pain Scale. Available at: http://prc.coh.org/PainNOA/ABBEY_D.pdf. Accessed: 2nd May 2012.…