Demonstrate understanding of electronic health record

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Reference no: EM133511738

Question 1: PROFESSIONAL IDENTITY

Adhere to all behaviors outlined in the Guidelines for Professional Conduct, ITCC Nursing Student Handbook.
Adhere to the professional nursing code of ethics and standards of practice. (ANA)
Demonstrate ethical and legal principles in the delivery of patient care. (NLN)
Maintain confidentiality of organization and patient.
Employ strategies to empower patients or families in all aspects of the health care process. (Q) (NLN)
Create educational goals appropriate to the clinical experience.
Use self-evaluation and faculty feedback to determine the effectiveness of one's practice and the need for change.
Accept instructor/staff feedback positively and utilizes constructive feedback to improve performance.
Demonstrates resourcefulness and self-directed learning to improve abilities to provide safe, competent patient care.
Demonstrate time management and prioritization.
Maintain a confident demeanor in skills and interactions with the patient or patient's family/significant others.

Question 2: PROFESSIONAL IDENTITY - COMMENTS (required - provide justification as to why you selected the above rating for this category)

Question 3: PATIENT CENTERED CARE AND HUMAN FLOURISHING:

Act with integrity, impartiality, and respect for differing views in the provision of patient care. (Q)
Respect and safeguard the property of the patient and their right to privacy. (NLN)
Protect and promote the patient's comfort and dignity. (NLN)
Assess mental status and other factors affecting care, including coping behaviors, potential for violence, other inappropriate/abnormal behavior (Q)
Assess family dynamics to determine plan of care; structure, bonding, communication, boundaries, coping mechanisms.
Avoid word choices from common language that promote stigmas of mental illness.
Follow assessment protocols for specific interventions and diagnoses; substance detoxification and standardized assessment scales.
Provide care for a patient experiencing visual, auditory or cognitive distortions; hallucinations.
Assist patient with achieving and maintaining self-control of behavior (e.g. No-Self-Harm Contract) while establishing appropriate patient/nurse boundaries.
Orient the patient to reality as appropriate.
Participate in group sessions within the mental health setting as appropriate.
Demonstrate awareness of the psychosocial effects on the patient's health status. (Q)
Demonstrate awareness of and attempts to respond to patient's psychosocial, spiritual, cultural and learning needs. (NLN)
Verbal and non-verbal communication convey empathy, respect, and cultural sensitivity toward patient/family/significant others, healthcare team, and instructor. (Q)

Question 4: PATIENT CENTERED CARE AND HUMAN FLOURISHING - COMMENTS (required - provide justification as to why you selected the above rating for this category)

Question 5: EVIDENCE BASED PRACTICE and NURSING JUDGEMENT

Apply knowledge of behavioral treatment relevant to patient's health status.
Demonstrate understanding of data from various sources to determine patient needs (e.g. lab data, assessment data, emotional status). (Q)
Correlate medications to the patient's health status.
Discuss the role of the Associate Degree Nurse in analyzing data to identify patient emotional, and/or psychological needs.
Discuss the plan of care based on nursing scope of practice for patients experiencing mental health issues and assists with identification of appropriate nursing diagnoses. (Q)
Demonstrate awareness of physical alterations that may influence psychological functioning.
Provide care and education for acute and chronic behavioral health issues; anxiety, depression, dementia, eating disorders.
Recognize non-verbal cues to physical and/or psychological stressors. (Q)

Question 6: EVIDENCE BASED PRACTICE and NURSING JUDGEMENT - COMMENTS (required - provide justification as to why you selected the above rating for this category):

Question 7: TEAMWORK AND COLLABORATION & SPIRIT OF INQUIRY

Coordinate and collaborates patient's care with the inter/intraprofessional healthcare team. (Q)
Demonstrate a commitment to team-work by assisting other team members and peers as appropriate, including volunteering for non-patient care activities, when appropriate. (Q)
Recognize awareness of own strengths and limitations as a team member and makes needed changes. (Q)
Demonstrate appropriate use of I-SBAR-R in communication with inter/intraprofessional team. (Q)
Alter communication techniques to meet individual needs of others; e.g. alters techniques for individuals with sensory deficits. (Q)
Demonstrate awareness of cultural influences on communication using appropriate language and grammar. (Q)
Use therapeutic communication techniques including active listening to provide patient support and build trust to promote nurse/patient relationship.
Keep inter/intraprofessional team members and instructor informed of patient's status throughout the shift. (Q)
Provide and participate in I-SBAR-R related to patient status throughout the shift, as appropriate.
Employ communication technique of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) in delivery of patient care.
Collaborate with faculty/staff to coordinate frequency of assessment based on changes in patient's clinical status>

Question 8: TEAMWORK AND COLLABORATION & SPIRIT OF INQUIRY - COMMENTS (required - provide justification as to why you selected the above rating for this category):

Question 9: SAFETY, QUALITY IMPROVEMENT & INFORMATICS:

Consistently implement agency-specific injury prevention protocols, recognizing and managing factors that may result in patient injury. (NPSG)
Implement and adheres to standard precautions. (NPSG)
Identify patient utilizing 2 identifiers according to agency policy prior to performance of procedures. (NPSG)
Anticipate need for instructor and/or staff nurse supervision for procedures and coordinate with instructor appropriately.
Assess and periodically reassess patients' risk and takes action to address any identified concerns. (Q).
Medication Administration

Understand appropriate technique to administer medications (proper identification of the patient utilizing at least 2 identifiers, verification of allergies, etc.). (NPSG)
Identify the 6 Rights of medication administration.
Nursing Informatics

Utilize current technology to assess and provide safe and effective patient care. (Q)
Demonstrate understanding of electronic health record and related to clinical facility policies to document patient plan of care (Q)
Demonstrates understanding of principles of legal documentation, such as appropriate method to note documentation errors, incident or event reports, signature requirements, etc.

Question 10: SAFETY, QUALITY IMPROVEMENT & INFORMATICS - COMMENTS (required - provide justification as to why you selected the above rating for this category):

Question 11: What skills, procedures or testing did you observe at clinical this week? What skills did you perform? Add any information here you wish to share with your clinical instructor.

Question 12: Identify your personal S.M.A.R.T. goal for the next clinical rotation. (A S.M.A.R.T. goal is SPECIFIC, MEASURABLE, ATTAINABLE, RELEVANT, and includes is TIME-BOUND.)

Question 13 - Were you able to attain the SMART goal you set for yourself for this clinical rotation? If so, how? If not, how will you work to achieve the goal on your next clinical rotation?

Reference no: EM133511738

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