Legal policy

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Dallas Baptist University *

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Nov 24, 2024

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AGACNPs have a responsibility and the capacity to influence current and future healthcare practices within their community, state, nationally, and globally. The 2010 Institute of Medicine report on The Future of Nursing: Leading Change, Advancing Health highlights the value and importance of including the nursing perspective and presence with advanced decision- making roles including policy development. Upon graduation, you will have the education, experiences, and unique health perspectives that equip you to actively participate in health policy. Despite learning these skills, AGACNPs are underrepresented in policy discussions, which can lead to critical oversights impacting healthcare delivery. For example, nurses were excluded from the President Trump’s Coronavirus Task Force as well as Biden’s Transition COVID-19 Advisory Board. This omission of nurses created a lack of interdisciplinary perspectives to a national and global health problem that affected patient outcomes, as well as the community and national health. The Future of Nursing 2020-2030, calls upon nurses to participate, inform and implement policies that will affect the greatest number of people in the most profound ways. AGACNPs must speak with a united voice on health issues that affect nursing practices and the health outcomes of our patients. AGACNPs need to increase their visibility and influence regarding their perspectives with shaping public health policy at the academic, health system, and research levels. We can influence health policy by engaging in the policy process on various levels, which includes interpreting, evaluating, and leading policy change. Slide 3: As AGACNPs with a master’s or hopefully soon doctorate degree, it will be imperative to engage in advocacy. Per the American Nurses’ Association’s Code of Ethics, the nurse will promote, advocate for, and protect the rights, health, and safety of the patient. Providing quality, affordable, and ethical care to patients is the epicenter of nursing and advocating. The World Health Organization has emphasized that a key role of nurses within health policy development is to ensure high quality care for patients.
Per the American Association of College’s of Nursing, The Essentials: Core Competencies for Professional Nursing Education , advanced practice nurses are able to advocate for professional nursing to ensure optimal outcomes, advocate for policy at all levels, analyze the effect and efforts of policy, and participate in the policy implementation process. Nurses are commited to ensuring high quality, humane, and respectful patient care that values all people holisitically. Because of this commitment, as well as the experience and knowledge that AGACNPs posess regarding patient care, they must advoacte for continual improvement. Lawmakers across the country need to be apprised to the issues that affect patients and the AGACNP role. This requires grassroot efforts by AGACNPs and various nursing organizations to come together with one voice to provide meaning and understanding to the issues that effect healthcare. AGACNPs offer their knowledge and experience with nursing skills such as communication, clinical experience, empathy, and ability to manage conflict, which are transferrable skills to policy development and public advocacy. Slide 4: Some of the patient care issues which an AGACNP should advocate for include protecting patients from harm, encouraging patient autonomy, fostering collaboration, and providing patients and family information for informed decision making. Within the acute care setting, AGACNPs will need to evaluate and advocate for their patients’ informed decision making capacity. Informed decision making capacity includes the patient’s ability to understand the risks and benefits, and alternatives toward a proposed treatment or intervention including no treatment. Slide 5: The AGACNP can assess and advocate their patient’s capacity of informed decision making or consent when the patient understands their situation and consequences, elicit reasoning within their thought process, and communicates their wishes. Some common risk factors of impaired medical decision making capacity include elderly patients, patients with a chronic pyschiatric or neurological condition, patients with low education level, or patients with cultural or language barriers,
as well as reversible causes of incapacity including infection, medications, illicit drugs, hypoxia, metabolic derangements, deliurium, and critical illness. AGACNPs will need to be attuned to these patient conditions and advocate for patients who lack capacity. If there is uncertainty of a patient’s capacity, the final judgement should err on the side to protect the patient. The AGACNP should be mindful of their state’s definition of capacity, as this can vary across the United States. Slide 6: AGACNPs can partcipate with policy changes by learning about the legislative process, contacting or meeting elected officials, and providing expert testimony to assist and inform with policy decisions. The ANA has an advocacy toolkit, which comprises of the various straetgies that nurses can take to become more politically involved. The ANA recommends knowing who represents you within Congress and emailing, calling, or scheduling a meeting with them to investigate where your representative stands on specific health care issues. Attending town halls gives consituents an opportunity to offer insight on ideas and interact with elected officials within their community, state, or nation. Advocacting for and within your community can include economic matters, educational issues, and healthcare system issues, but can also represent the creation of organizations in which the constituents share a common goal. AGACNPs can assess and advocate issues where a need is apparent. This can include sharing healthcare costs within a community, providing information on community resources available, improving access to care, and providing expertise within public forums. Examples of possible community specific acute care political issues include infectious diseases like COVID-19 or HIV, human trafficking, violence, illicit drug use including medical cannabis, and contaminated water which can all effect the health of our patients. AGACNPs can also be active members within various nursing and healthcare organizations within their community, state, nationally, or globally. A few nursing organzations include the American Association of Nurse Practitioners, the Gerontological Advanced Practice Nurses Association, as well as your state’s nurse practitioner organization.
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Becoming a member within these organizations allows for educational opportunities, mentorship, connection, legislative support, up to date information, marketability, and role advancement. Slide 7: Common federal health care policies or Acts that the AGACNP should be mindful of include the Emergency Medical Treatment and Labor Act or EMTALA, the Health Insurance Portability and Accountability Act or HIPPA, and the Patient Safety and Quality Improvement Slide 8: AGACNPs also have a duty to advocate for the nursing role and practicing at the full scope of their practice, certification, and licensure in order to influence regulation and legislation. As future advanced practice nurses, it is essential to know your state’s laws regarding the AGACNP’s scope of practice. At the national level, some of the federal agencies that impact AGACNP practice include the Centers for Medicare and Medicaid Services, the CDC, the Federal Employees Health Benefits program, the Federal Trade Commission, the U.S. Food and Drug Administration, National Institutes of Health, and Veterans Affairs. At the state level, boards of nursing regulate APRN practice through nurse practice acts and other laws and regulations. The APRN Consensus model for Licensing, Accreditation, Certification, and Education or LACE model provides guideance for states to adopt uniformity regarding APRN regulation but despite this model there continues to be states that vary widely regarding APRN practice and regulation. The AGACNP certification is recognized by a national certifying body through either the American Nurses Credentialing Center or ANCC and the American Association of Critical Care Nurses or AACN. Once you complete the AGACNP program, you will be taking either the ANCC or AACN certification exam. National certification and licensure in the state is required, but each state has their own State Nurse Practice Acts that delineate the legal scope within each state. Examples of these varying legal scopes of practices include use of title, prescriptive authority, and practice requirements.
Slide 9: As AGACNPs, it is imperative to also advocate for yourself. This can include safety concerns within the workplace, professional wellness and wellbeing, and the highly skilled role AGACNPs contribute within the healthcare system. AGACNPs can advocate through partcipating in activities that influence decision making, join practice committees, and collaborate with nurse leaders. Skills required to advocate for yourself include communicating effectively, knowledge of your scope of practice, knowing who to go to, and getting involved. An example of advocating for yourself, which can happen in the acute care setting, is when a provider will need to terminate their professional relationship with a patient for numerous reasons including aggressive behavior, tampering with prescriptions, lying, and drug seeking behavior. The AGACNP should be aware of the potential liability, including patient abandonment. To avoid the liability for abandonment, the provider needs to terminate the patient relationship by giving the patient notice, reasonable opportunity to find substitute care, and information on how to obtain their medical records. Slide 10: The Institute of Medicine provides a framework to assess and guide quality initiatives within the private and public sectors throughout healthcare, which includes providing safe, effective, person-centered, timely, efficient, and equitable care. According to the , Joint Commission on Accreditation of Healthcare Organizations or JCAHO the Agency for Healthcare Research and Quality providing safe care includes avoiding harm to patients from the care that is intended to help them. For example, created a universal
protocol, which was designed to improve safety and reduce the occurrence of procedural errors. This protocol requires organizations to perform a time-out for all procedures, which requires the team to review the patient’s identity, the procedure for which the patient was consented, and the site where the procedure will be performed before the procedure can begin. This time out procedure also allows any team members to voice any concerns about the patient’s safety of the procedure before beginning. Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit is classified as effective care. This includes avoiding underuse and misuse of care. The IOM defined overuse as the use of health care resources and procedures in the absence of evidence that the service could help the patient, and misuse was defined as failure to execute clinical care plans and procedures properly. According to the Emergency Care Research Institute, an essential element for person centered care includes the shared decision making between the provider with the individuals’ preferences and goals for their own healthcare and wellbeing. This is becoming ingrained within federal and state reimbursement policies, so the patient can choose what is right for them as well as achieving cost savings. The U.S. Centers for Medicare and Medicaid Services requires shared
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decision making as a condition of reimbursement for certain cardiovascular and stroke prophylaxis procedures, and lung cancer screenings. Person-centered care means providers work collaboratively with patients and other health care members to do what is best for the patients’ health and well-being. By collaboratively working together with the patient and various healthcare providers, they are better equipped to develop care plans that include empathy, dignity and respect with patients and their families. According to AHRQ, timeliness includes reducing waits and harmful delays for both those who receive and those who give care. Within acute care there can be t avoid waste, including waste of equipment, supplies, ideas, and energy. According to the IOM, six areas of major healthcare waste include unnecessary services, inefficient delivery of care, excess administrative costs, inflated prices, prevention failures, and fraud. Attention must be observed to these six forms of waste to conserve scarce health resources and funds. hree types of delays – input delays, which are delays in access to a service such as a hospital bed once a decision is made to admit; throughput delays, which are delays affecting the length of time between a
patient's admission and the time they are ready to be discharged from the hospital; and output delays, which are delays in the amount of time it takes to get a patient discharged from the hospital, such as a delay caused by a lack of availability of beds at a transitional care facility. The care we provide also needs to be efficient, meaning we Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status is equitable. Equity is about fairness and justice in that everyone should have an equal opportunity to use and attain health care. There are many social factors that contribute to one’s ability to achieve healthy outcomes including ethnicity, language, religion, socioeconomic status, gender, and sexuality. Providers need to recognize when and how a person’s social determinants can impact their health outcomes for specific populations. If a health outcome varies between populations, there is disparity, or lack of equity. An example of a health disparity includes during the COVID-19 pandemic. Black, Hispanic, and American Indian’s were three times more likely to be hospitalized and twice as likely to die from COVID-19.
To reduce health disparities, the Centers for Medicare & Medicaid Services created the Accountable Health Communities Model. This model addresses the gap between care by identifying and addressing the social needs through screening, referral, and community navigation services to reduce health care utilization and costs. With identification and solving a person’s unstable housing, or food insecurity, for example, this may reduce the risk of one developing a chronic condition which can lead to increased healthcare costs and avoidable health care utilization. Under the Affordable Care Act section 4302, it is required to collect and report race, ethnicity, primary language, and disability status variables to understand the causes of health disparities and create effective solutions to ensure health equity. Aims for the health system Definition Implications within acute care Safe Effective Avoiding harm to patients from the care that is intended to help them Providing services based on scientific knowledge to all who could benefit (avoiding underuse or misuse) Medication errors; timeout procedures
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Overuse of antibiotics or CT scans (radiation exposure) Patient Centered Providing care that is respectful of and responsive to individual patient preferences, needs, and values. Ensuring the patient’s Patient-family advisory councils AGACNPs have a responsibility and the capacity to influence current and future healthcare practices within their community, state, nationally, and globally. The 2010 Institute of Medicine report on The Future of Nursing: Leading Change, Advancing Health highlights the value and importance of including the nursing perspective and presence with advanced decision- making roles including policy development. Upon graduation, you will have the education, experiences, and unique health perspectives that equip you to actively participate in health policy. Despite learning these skills, AGACNPs are underrepresented in policy discussions, which can lead to critical oversights impacting healthcare delivery. For example, nurses were excluded from the President Trump’s Coronavirus Task Force as well as Biden’s Transition COVID-19 Advisory Board. This omission of nurses created a lack of interdisciplinary perspectives to a national and global health problem
that affected patient outcomes, as well as the community and national health. The Future of Nursing 2020-2030, calls upon nurses to participate, inform and implement policies that will affect the greatest number of people in the most profound ways. AGACNPs must speak with a united voice on health issues that affect nursing practices and the health outcomes of our patients. AGACNPs need to increase their visibility and influence regarding their perspectives with shaping public health policy at the academic, health system, and research levels. We can influence health policy by engaging in the policy process on various levels, which includes interpreting, evaluating, and leading policy change. Slide 3: As AGACNPs with a master’s or hopefully soon doctorate degree, it will be imperative to engage in advocacy. Per the American Nurses’ Association’s Code of Ethics, the nurse will promote, advocate for, and protect the rights, health, and safety of the patient. Providing quality, affordable, and ethical care to patients is the epicenter of nursing and advocating. The World Health Organization has emphasized that a key role of nurses within health policy development is to ensure high quality care for patients. Per the American Association of College’s of Nursing, The Essentials: Core Competencies for Professional Nursing Education , advanced practice nurses are able to advocate for professional nursing to ensure optimal outcomes, advocate for policy at all levels, analyze the effect and efforts of policy, and participate in the policy implementation process. Nurses are commited to ensuring high quality, humane, and respectful patient care that values all people holisitically. Because of this commitment, as well as the experience and knowledge that AGACNPs posess regarding patient care, they must advoacte for continual improvement. Lawmakers across the country need to be apprised to the issues that affect patients and the AGACNP role. This requires grassroot efforts by AGACNPs and various nursing organizations to come together with one voice to provide meaning and understanding to the issues that effect healthcare. AGACNPs offer their knowledge and
experience with nursing skills such as communication, clinical experience, empathy, and ability to manage conflict, which are transferrable skills to policy development and public advocacy. Slide 4: Some of the patient care issues which an AGACNP should advocate for include protecting patients from harm, encouraging patient autonomy, fostering collaboration, and providing patients and family information for informed decision making. Within the acute care setting, AGACNPs will need to evaluate and advocate for their patients’ informed decision making capacity. Informed decision making capacity includes the patient’s ability to understand the risks and benefits, and alternatives toward a proposed treatment or intervention including no treatment. Slide 5: The AGACNP can assess and advocate their patient’s capacity of informed decision making or consent when the patient understands their situation and consequences, elicit reasoning within their thought process, and communicates their wishes. Some common risk factors of impaired medical decision making capacity include elderly patients, patients with a chronic pyschiatric or neurological condition, patients with low education level, or patients with cultural or language barriers, as well as reversible causes of incapacity including infection, medications, illicit drugs, hypoxia, metabolic derangements, deliurium, and critical illness. AGACNPs will need to be attuned to these patient conditions and advocate for patients who lack capacity. If there is uncertainty of a patient’s capacity, the final judgement should err on the side to protect the patient. The AGACNP should be mindful of their state’s definition of capacity, as this can vary across the United States. Slide 6: AGACNPs can partcipate with policy changes by learning about the legislative process, contacting or meeting elected officials, and providing expert testimony to assist and inform with policy decisions. The ANA has an advocacy toolkit, which comprises of the various straetgies that nurses can take to become more politically involved. The ANA recommends knowing who represents you within Congress and emailing, calling, or scheduling a meeting with them to investigate
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where your representative stands on specific health care issues. Attending town halls gives consituents an opportunity to offer insight on ideas and interact with elected officials within their community, state, or nation. Advocacting for and within your community can include economic matters, educational issues, and healthcare system issues, but can also represent the creation of organizations in which the constituents share a common goal. AGACNPs can assess and advocate issues where a need is apparent. This can include sharing healthcare costs within a community, providing information on community resources available, improving access to care, and providing expertise within public forums. Examples of possible community specific acute care political issues include infectious diseases like COVID-19 or HIV, human trafficking, violence, illicit drug use including medical cannabis, and contaminated water which can all effect the health of our patients. AGACNPs can also be active members within various nursing and healthcare organizations within their community, state, nationally, or globally. A few nursing organzations include the American Association of Nurse Practitioners, the Gerontological Advanced Practice Nurses Association, as well as your state’s nurse practitioner organization. Becoming a member within these organizations allows for educational opportunities, mentorship, connection, legislative support, up to date information, marketability, and role advancement. Slide 7: Common federal health care policies or Acts that the AGACNP should be mindful of include the Emergency Medical Treatment and Labor Act or EMTALA, the Health Insurance Portability and Accountability Act or HIPPA, and the Patient Safety and Quality Improvement organizations support the active participation of AGACNPs within health policy to improve Many of these
health care access, cost of care, health equality, health legislation, and nursing’s scope of practice. Act or PSQIA. AGACNPs need to have the awareness of these laws and how they effect the patients they care for and treat. Health Care Acts Definition Implications EMTALA HIPPA PSQIA A federal law that requires any patient who seeks treatment in an emergency room must be stabilized, and treated regardless of their insurance status or ability to pay. national standards to protect sensitive patient Ensures access to healthcare and reduces financial barriers. Requires providers A federal law that requires the creation of
to screen and treat emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed or color. Individually identifiable health information including names, geographic identifiers health information from being disclosed without the patient’s consent or knowledge. including street address, city, zip code; dates related to an individual like birth date, admission date; telephone numbers; FAX numbers; e-mail addresses; social security
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numbers; medical record numbers; health plan beneficiary numbers; and account numbers; must not be disclosed without the patients’ Federal Act which establishes a voluntary authorization or legal authority. Federal legal privilege and confidentiality reporting system designed to enhance the data and health care quality issues, and to protections to information that is reported by available to assess and resolve patient safety
providers and limits the use of this information in criminal, civil, and encourage the reporting and analysis of administrative proceedings. There are medical errors. provisions for monetary penalties for violations of confidentiality or privilege protections. Slide 8: AGACNPs also have a duty to advocate for the nursing role and practicing at the full scope of their practice, certification, and licensure in order to influence regulation and legislation. As future advanced practice nurses, it is essential to know your state’s laws regarding the AGACNP’s scope of practice. At the national level, some of the federal agencies that impact AGACNP practice include the Centers for Medicare and Medicaid Services, the CDC, the Federal Employees Health Benefits program, the Federal Trade Commission, the U.S. Food and Drug Administration, National Institutes of Health, and Veterans Affairs. At the state level, boards of nursing regulate APRN practice through nurse practice acts and other laws and regulations. The APRN Consensus model for Licensing, Accreditation, Certification, and Education or LACE model provides guideance for states to adopt uniformity regarding APRN regulation but despite this model there continues to be states that vary widely regarding APRN practice and regulation. The AGACNP certification is recognized by a national
certifying body through either the American Nurses Credentialing Center or ANCC and the American Association of Critical Care Nurses or AACN. Once you complete the AGACNP program, you will be taking either the ANCC or AACN certification exam. National certification and licensure in the state is required, but each state has their own State Nurse Practice Acts that delineate the legal scope within each state. Examples of these varying legal scopes of practices include use of title, prescriptive authority, and practice requirements. Slide 9: As AGACNPs, it is imperative to also advocate for yourself. This can include safety concerns within the workplace, professional wellness and wellbeing, and the highly skilled role AGACNPs contribute within the healthcare system. AGACNPs can advocate through partcipating in activities that influence decision making, join practice committees, and collaborate with nurse leaders. Skills required to advocate for yourself include communicating effectively, knowledge of your scope of practice, knowing who to go to, and getting involved. An example of advocating for yourself, which can happen in the acute care setting, is when a provider will need to terminate their professional relationship with a patient for numerous reasons including aggressive behavior, tampering with prescriptions, lying, and drug seeking behavior. The AGACNP should be aware of the potential liability, including patient abandonment. To avoid the liability for abandonment, the provider needs to terminate the patient relationship by giving the patient notice, reasonable opportunity to find substitute care, and information on how to obtain their medical records. Slide 10: The Institute of Medicine provides a framework to assess and guide quality initiatives within the private and public sectors throughout healthcare, which includes providing safe, effective, person-centered, timely, efficient, and equitable care. According to the , Joint Commission on Accreditation of Healthcare Organizations or JCAHO
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the Agency for Healthcare Research and Quality providing safe care includes avoiding harm to patients from the care that is intended to help them. For example, created a universal protocol, which was designed to improve safety and reduce the occurrence of procedural errors. This protocol requires organizations to perform a time-out for all procedures, which requires the team to review the patient’s identity, the procedure for which the patient was consented, and the site where the procedure will be performed before the procedure can begin. This time out procedure also allows any team members to voice any concerns about the patient’s safety of the procedure before beginning. Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit is classified as effective care. This includes avoiding underuse and misuse of care. The IOM defined overuse as the use of health care resources and procedures in the absence of evidence that the service could help the patient, and misuse was defined as failure to execute clinical care plans and procedures properly. According to the Emergency Care Research Institute, an essential element for person
centered care includes the shared decision making between the provider with the individuals’ preferences and goals for their own healthcare and wellbeing. This is becoming ingrained within federal and state reimbursement policies, so the patient can choose what is right for them as well as achieving cost savings. The U.S. Centers for Medicare and Medicaid Services requires shared decision making as a condition of reimbursement for certain cardiovascular and stroke prophylaxis procedures, and lung cancer screenings. Person-centered care means providers work collaboratively with patients and other health care members to do what is best for the patients’ health and well-being. By collaboratively working together with the patient and various healthcare providers, they are better equipped to develop care plans that include empathy, dignity and respect with patients and their families. According to AHRQ, timeliness includes reducing waits and harmful delays for both those who receive and those who give care. Within acute care there can be t avoid waste, including waste of equipment, supplies, ideas, and energy. According to the IOM, six areas of major healthcare waste include unnecessary services, inefficient delivery of care, excess administrative costs, inflated prices, prevention failures, and fraud.
Attention must be observed to these six forms of waste to conserve scarce health resources and funds. hree types of delays – input delays, which are delays in access to a service such as a hospital bed once a decision is made to admit; throughput delays, which are delays affecting the length of time between a patient's admission and the time they are ready to be discharged from the hospital; and output delays, which are delays in the amount of time it takes to get a patient discharged from the hospital, such as a delay caused by a lack of availability of beds at a transitional care facility. The care we provide also needs to be efficient, meaning we Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status is equitable. Equity is about fairness and justice in that everyone should have an equal opportunity to use and attain health care. There are many social factors that contribute to one’s ability to achieve healthy outcomes including ethnicity, language, religion, socioeconomic status, gender, and sexuality. Providers need to recognize when and how a person’s social determinants can impact their health outcomes
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for specific populations. If a health outcome varies between populations, there is disparity, or lack of equity. An example of a health disparity includes during the COVID-19 pandemic. Black, Hispanic, and American Indian’s were three times more likely to be hospitalized and twice as likely to die from COVID-19. To reduce health disparities, the Centers for Medicare & Medicaid Services created the Accountable Health Communities Model. This model addresses the gap between care by identifying and addressing the social needs through screening, referral, and community navigation services to reduce health care utilization and costs. With identification and solving a person’s unstable housing, or food insecurity, for example, this may reduce the risk of one developing a chronic condition which can lead to increased healthcare costs and avoidable health care utilization. Under the Affordable Care Act section 4302, it is required to collect and report race, ethnicity, primary language, and disability status variables to understand the causes of health disparities and create effective solutions to ensure health equity. Aims for the health system Definition Implications within acute care
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Safe Effective Avoiding harm to patients from the care that is intended to help them Providing services based on scientific knowledge to all who could benefit (avoiding underuse or misuse) Medication errors; timeout procedures Overuse of antibiotics or CT scans (radiation exposure) Patient Centered Providing care that is respectful of and responsive to individual patient preferences, needs, and values. Ensuring the patient’s Patient-family advisory councils eating okay? You would put positive and negative in your review of systems. You also would have your labs, any tests that you've ordered and have come back, and any other diagnostics that you've had, you'd put in your H and P also includes your problem focus or comprehensive physical exam of your patient, as well as your assessment and plan for admission. Slide 27: Discharge Summary so this document includes the date of admission and the date of discharge. You also want to have any consulting services that were utilized during this hospital stay and why they were consulted. You also
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want to have the principal diagnosis, which is the main problem that you've identified in this hospitalization, as well as any additional or secondary diagnosis that the patient could have. And this includes any kind of chronic disease processes. You'll have a section where you put the HPI of the admission of what brought the patient, and then another paragraph will be the hospital event. So this is where you tell the story of the whole hospitalization. It's obviously easier to summarize that when a patient's only been there for a few days, but when you have a patient there for months, this could be quite difficult to write up sometimes because a lot of things happen, but you want to write in your note any complications, any surgeries, procedures. Sometimes you need to put the antibiotic regimens they were on when they started and stopped. You really want to write a great summary of what the patient encountered during this hospital stay. You also include pertinent labs, tests, and findings in your discharge summary. So when the patient follows up with their primary care physician or any kind of they need to follow up with cardiology or neurology, they can see what tests you did at this hospitalization. You also want to remember to put your patient's condition at discharge. Either they were stable, they left against medical advice. You want to put their discharge location either they went home or inpatient rehab or long term acute care facility or LTAC. You also want to include your discharge instructions for the patient, which includes their diet and activity, as well as follow up appointments and referrals that you made for the patient. And then finally, you want to make sure you have the list of medications and prescriptions that you prescribe the patient. And again, this will all be sent to the patient's primary care physician or any kind of consulting service or referral that you sent so they can exactly see what happened this hospitalization. And it's a great communication tool, so you want to make sure it's very detailed and correct.
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