What does it mean to document accurately and appropriately?

What does it mean to document accurately and appropriately?

To document appropriately and accurately in the medical field means ensuring that records are created for every service provided by any medical practitioner, either nurses, doctors and any other staff. It is vital for such information to in good condition, comprehensible and more transparent for all the users of the information such as the patient, payors, government agencies, legal system, researchers, accrediting groups and any other interested party (Webb,& Pass, 2004, p 35).
What are the documenting guidelines? When is it appropriate to use abbreviations?

To ensure that documentation is accurate and appropriate, the medical practitioners adhere to documenting guidelines which are laid down as fundamental aspects of documentation. They include being factual. This means that medical records have to contain descriptive and objective information about what a practitioner sees, feels, hears and smells (Hammond, Boyce,  Briceland, Canaday, Carr-Lopez, Eggleston, & Hudson, 2003, p 90). Documentation has to be accurate, which is asserted through the provision of exact measurements. This helps to asses any minor change to a patient which can be fatal. Documentation has to be complete; hence no information, however slight it is should be left out. All avenues of collecting data have to be explored, such as communicating with the client’s family members as well as being thorough with checkups. Documentation also has to be timely (Hammond, Boyce,  Briceland, Canaday, Carr-Lopez, Eggleston, & Hudson, 2003, p 91). Ensuring that entries are made punctually is vital to the ongoing client’s care since it helps reflect a clear record of what is happening to them at all times. Abbreviations are commonly used in both clinical and general world mostly to facilitate simplicity in communication. More so they are used to help in saving time, effort as well as space. However, abbreviations should only be used when the intended reader fully understand the abbreviation to avoid confusion.
What is the difference between subjective and objective data?

In the medical field, subjective data refers to information from a patient’s point of view, which represents the symptoms. They include perceptions, feelings, as well as concerns which are usually acquired through an interview. Objective data refers to information obtained through observing and measuring the patient (Bieber, Seidel, & Portwich,2017, June, p 401). Such information is acquired through observation, testing done in the laboratory as well as a diagnosis as well as a physical examination.

What does it mean to demonstrate clinical reasoning skills?

Demonstrating clinical reasoning is the medical practitioner’s way of expressing their ability to integrate and apply their knowledge when weighing the evidence. This is done through critical thinking and reflection on the process used t arrive at a particular diagnosis.
How can you use clinical reasoning to plan the organization of a comprehensive exam?

A situation-based questionnaire can be implemented to plan for a comprehensive exam as well as trough asking the students to respond basing their response on their critical and cognitive thinking abilities
How will you document variations of normal and abnormal assessment findings?

It should be done in a two-column format to distinguish between the two. Step by step photos should also be used to ensure clarity of the examination techniques employed as well the expected findings and the actual outcomes.
What factors influence the appropriate tools and tests necessary for a comprehensive assessment?

Factors that influence the appropriate tools and tests necessary for a comprehensive assessment includes the patient’s individual sociological, spiritual, physiological and psychological needs.
Reflect on personal strengths, limitations, beliefs, prejudices, and values.

While practising, one should not have any prejudice or bring it forward. One should respect that the practitioners have the authority to make any called for health decisions. One should understand that personal beliefs should not be part or should not affect them while practising. Every patient should be viewed with individualism. A practitioner’s strength includes thorough listening skills without biasness and also giving the patient enough time to ensure that subjective data is collected effectively. Also, as a practitioner, one should not oversee the patient’s information
How will these impact your ability to obtain a comprehensive health history?

It is through strengths, limitations, beliefs, values and prejudice that sufficient, comprehensive health history is collected.

How can you develop strong communication skills?

Communication can be improved through perfecting in listening skills, prioritizing communication, not deviating from the message and being straightforward, engaging the readers and listeners, taking time to respond, fully understanding, maintaining eye contact and also observing body language (Sperr, Baldwin, Feeney, & Herring,2018, p 29).
What interviewing techniques will you use to interview the patient to elicit subjective health information about their health history?

Understanding the body language, being in a convenient place such as a quiet place, establishing a rapport, respecting the patient’s privacy, recognizing facial expressions and asking open-ended questions (Shea,2016, p 31).

What relevant follow-up questions will you use to evaluate patient condition?

How are you since your last visit? Have you experienced any symptoms of the illness since your last visit? Did you finish all the prescribed medicine?
How will you demonstrate empathy for patient perspectives, feelings, and sociocultural background?

Nodding while talking to them, showing that you understand how they feel by the use of a soft tone, initiating a conversation about where they come from or something they are familiar with.
What opportunities will you take to educate the patient?

Finding out what they know and correcting them where they are wrong.

What are the barriers you face to collecting a comprehensive health history so that you can give culturally-competent care?

The language barrier, unresponsive patient, un-cooperating patient.