Document using professional terminology,
□ □ □ □ □ X □
format and technology (ie: ICD9, E/M coding, CPT)
10-7-13 – 4
A. By documenting in professional terminology, using the appropriate format within the
office you are working and the appropriate technology allows your colleagues to
understand your thoughts and plan for patients within the practice. By doing this then
each provider has the same sense of what is going on with the patient. The challenge
in this outcome is learning to switch from an RN role to an APRN role and refocusing
your terminology and how you communicate with physicians and other APRN’s.
Also another challenge is learning all the different codes that exist within the medical
field.
B. Ex. 1 – With the patients that are coming into the office I have been able to code the
appointments after I have seen them. I have noticed that with the more comorbidities this office charges 99214 for these patients. Also most of the 99213
codes are used for the acute patients that present to the office. I feel confident in
choosing the correct codes for these different patients. Ex. 2 – When presenting my
patients with sinusitis I have been able to give detail information with using
professional terminology to my preceptor so that she can get the most information
from me so that she does not have to go into the room to do the whole appointment
over again.
C. To perform better with this outcome I need to just keep practicing on charting within
the chart and also applying the ICD9 codes and E/M codes to the patients after they
have been seen.
D. My preceptor has given me the opportunity to chart all my physical assessments,
ICD9 codes and E/M Codes within the computer into has helped me improve with my
professional terminology. More practice and repeativeness helps the best.
11-24-13 – 4
A. See above.
B. Ex. 1 – I had a patient came in with an injury to his knee and I was able to document
appropriately which tests I performed on his knee that were positive to help us
facilitate the need for an MRI to determine if his ACL was partially torn or fully torn,
and also the need for a orthopedic consult. Ex. 2 – I had another patient that came in
with a poison ivy rash on her extremities and torso. I was able to diagnosis the rash
and also give appropriate details on where the rash was and what the rash looked like.
C. Continue with above.
D. As I become more experienced in my nurse practitioner role I know my professional
terminology will improve and also how efficient I become with my charting.
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14.
Initiate referrals by collaborating and consulting with
□ □ □ □ □ X □
members of the health care team
10-7-13 – 3
A. Referring to an outside provider for care can be needed at times. This is where your
colleagues will come in useful in your practice. The health care team will help me
decide which provider works well with their patients and their clinic. Also by
involving the health care team in my decision on referring a patient will allow me to
have a better sense of what is needed to help that patient get the appropriate care they
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deserve. The challenge in meeting this outcome is knowing what outside providers
are accepting new patients and also what insurances are accepted by these providers
that I am referring to.
B. Ex. 1 – Was able to assist a female patient with a second opinion referral to an
orthopedic physician about her knee. She was needing a second opinion on what
could be done for her knee because the first surgeon did not want to do surgery yet
for her. Ex. 2 – Was able to help a male patient with a referral to a neurologist to
have his carpel tunnel evaluated so that he could have these results to take to the
orthopedic surgeon for possible correction of his carpel tunnel bilaterally.
C. Knowing the collaborating physicians that work with the clinic you are working with
and also knowing which providers are covered by the patient’s insurance or if they
accept the patients without insurance. Also a challenge is when starting out in my
own practice, is getting to know the physicians that I am working with and achieving
a good working relationship with these physicians.
D. I can use the referral department within the clinic that I work to help me facilitate
referrals for my patients. Up-to-Date and Epocrates will benefit when deciding on
whether to refer on.
11-24-13 – 4
A. See above.
B. Ex. 1 – Was able to refer a lady to a surgeon after we received her mammogram
which a lump was detected on a self-breast exam. She was grateful that she was able
to get in so quickly to see him and get the process started. Ex. 2 – Was able to refer a
gentlemen to a general surgeon to help us heal an abscess. We needed this wound
evaluated due to the fact he was going to have knee surgery within the month. We
needed him to see the general surgeon to determine if the abscess was healing and
would not affect the knee surgery. He was glad we did this because he did not want
anything holding up his surgery. He was able to have his knee surgery without any
complications.
C. Continue with above.
D. Continue with above.
Employ effective communication methods with patients,
□ □ □ □ □ □X
families, preceptor, and staff
11-24-13 – 5
A. As a student you need to learn how to provide information in different ways to the
different people you are talking to so that they understand what you are talking about.
When I give my preceptor my presentation about a patient needs to be in a
professional and descriptive manner so that she can understand my diagnosis and
what my treatment plan needs to be. When it comes to discussing with a patient
about what the treatment plan is then I need to adjust my presentation to them so that
they understand what I would like them to do so that they can get better. A challenge
for this outcome is that patients are all different and they understand information in
different ways. Some people like to be told things and are able to comprehend in that
fashion while others are picture learners that need the information in front of them so
that they better understand. Deciding on what type of learner your patient is, is an
outcome all to its self.
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B. Ex. 1 – When I have a child as a patient I try to ask them questions about what they
are feeling and what is wrong. By involving the child in the appointment makes them
feel that you are paying attention to them and where they are hurting. I believe I can
get a better feel of what is going wrong with the child when I am talking to them.
When the parents say they don’t feel good, I like to ask them where they hurt or if
they can point to where they hurt and tell me about their pain. I have noticed that the
children become open with me and then will let me examine them without much
resistance. Ex. 2 – I had a patient that I needed an EKG on I was able to talk to my
preceptors nurse in a professional why so that she knew why I needed on and why it
was important to have it done right away. I am respectful to the nursing staff at this
clinic so that they will be willing to help me when I need something for one of my
patients.
C. I feel that I am working at high standards in this outcome because I demonstrate
respect in communications with the staff, patients and my preceptor. Continuing to
have patience for the staff you work with and also the patients and their families can
only help with this outcome.
D. My resource within this outcome is by having my preceptor give me feedback on how
my bullet presentations on with her and also by me going and asking the nurse to help
my patients, instead of my preceptor finding her for me.
Communicate practice knowledge effectively both
□ □ □ □ □ □X
orally and in writing
11-24-13 – 5
A. This outcome is stating how well you are discussing your knowledge in your practice
through oral presentation to your clinical preceptor and in writing to your clinical
instructor. My oral presentations to my clinical preceptor are precise and in a timely
manner to get the best information to my preceptor so that we can take care of the
patient and give them the best care possible.
B. Ex. 1 – When I present my patients that have sinusitis I am able to present to my
preceptor in a timely fashion with precise terminology and my care plan and diagnosis
all planned out. I have become very efficient and precise in writing up my notes for my
preceptor to sign when I am done with the appointment so that she is not waiting on me
and that I am not wasting her time. I am independent with my charting within this
clinical setting. Ex. 2 – I have been use OLDCART with all my patients and have
become very confident that I am getting all the details that I need to make the
appropriate diagnosis for that certain patient so that they can receive the best treatment
plan for them.
C. My strength is using OLDCART when gathering information for my charting. My
challenge in this competency has been to orally present my patient to my preceptor
which is now a strength that I have within my current practice.
D. Using my Bates book to achieve the correct terminology when charting, using
OLDCART to gather information, chart the norms within the objective data to achieve
more practice in charting, and asking my preceptor about my progress and what I need
to be working on for my future practice.
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