Medication Reconciliation Assignment Analysis

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Medication Reconciliation Assignment Analysis



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Medicines reconciliation

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Popular Articles Keys to a Successful Implementation. New How do I fix a Smart Edits rejection? New Patient Rx History Consent. All rights reserved. In creating a care plan, it must have all relevant information about the patient. Apart from knowing and understanding patient conditions, diagnoses, and their definitions, healthcare providers are required to have critical thinking.

Follow these steps to develop a care plan for your patient. Step 1: Data Collection and Assessment The first step in nursing care plan creation is the data collection and assessment. The American Nursing Association ANA states that the assessment process must include different factors such as physical, psychological, sociocultural, spiritual, economic data, and lifestyle. The most common approach to this is through an interview and physical examinations.

Through this step, nurses can identify the risk factors and pertinent information which is critical so that they can make a diagnosis. Step 2: Data Analyses and Diagnoses After collecting patient data and assessment has been done, a diagnosis has to be made. A good care plan should define a diagnosis after analyzing and taking into consideration all gathered information about the patient. Usually, analysis of data involves comparison of patient data versus standards, clustering of cues, and identifying gaps and inconsistencies. One of the most cited references is the NANDA-I nursing care plan diagnoses as a way to identify, focus and deal with specific patient needs and how to respond to actual high-risk health problems.

Having a uniform standard of diagnoses eliminates confusion moving forward in the treatment and care plan of the patient. Step 3: Data Collection and Assessment Once diagnoses have been made, prioritization of findings should be established to determine the sequence of treatment and procedure to address patient needs. In this step, proper diagnoses are ranked based on their impact on patient health—life-threatening health problems are given high priority, and others determined to be either medium or low-risk are dealt with after.

For example, if a diabetic patient recently had a stroke and with existing comorbidities, healthcare providers should come up with one holistic care plan for the patient that addresses the most pressing health issue first. After which, goals or desired outcomes are set for each priority. Step 4: Nursing Intervention and Rationale of the Treatment Nursing interventions are the nursing orders which include the activities and actions that nurses have to perform to achieve the set goals for the patient.

In other words, these are the treatments that will be given or provided to the patient to address their health problems. It includes a checklist of the activities on how nurses will take care of the patient. As an evidence-based plan, documentation of treatment implementation is required. Results of the evaluation will determine the effectiveness of the intervention and care being provided to the patient and if the NANDA diagnosis needs to be modified or changed, or if the treatment plan has been completed and the patient is ready to go home.

The following are the purposes and importance of a nurse care plan: Define roles. The care plan helps establish the roles and responsibilities of each healthcare provider. Gives direction for the overall patient care. Ensures continuity of care. With presence of a care plan, nurses from different shifts, floors, or departments can refer to it. Having a care plan will ensure that the same care and type of intervention is provided to the patient. Nurses record all of the findings from their observations and monitoring, as well as actions carried out, instructions that the client or family members require.

If actions and care are not recorded, there is no evidence that they were carried out. Serves as a guide for proper staff assignment. The care plan can also be used as a reference to the type of nursing skills that the patient needs. Having this on hand can help determine the right staff with particular and precise skills to address patient needs. Guide for reimbursement. Medical records are also included in the care plan. Insurance companies also use this to determine what they will pay and how much they will pay in relation to the hospital care that the patient received.

Involves clients. Although it may seem that the care plan is only for nurses and other healthcare workers, this also benefits the patient as they get involved in their own treatment and care. Different types of Care Plans There are a vast variety of diseases out there that people may or may not contract in their lifetime. But whatever that may be, there is a care plan for that.

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