Nursing often needs accuracy and exercising professionalism whiledealing with the patients. More important, the studies require one toengage in intensive practical and theoretical activities that will behelpful in understanding various concepts. The presence of thepreceptors tends to be essential since they can guide us in anyactivities that might seem ambiguous. This paper analyzes how I oftendeal with diagnostic testing, how I document the data and theimportance of the electronic health record system in managing theinformation.
The process of diagnostic testing clearly benefits from knowledge inphysical assessment as well as pathophysiology. Together with mypreceptor, we often have to gather information and interpret it tounderstand whether the patient is on any medication. Besides that, wealso conduct a clinical history through a proper interview in orderto reach the required outcomes. Later, we will even undertake aphysical exam that reveals any suspicious symptoms that might show aserious illness (Geisler et al., 2014). Looking at priorprobabilities and consulting with the other clinicians tend to bemore crucial. However, when the process does not determine theproblem that the patient is facing, then there will be the need tointervene with the diagnostic testing. In this case, the approachwill identify the illness that the patient is experiencing at thatparticular time and determine the exact method to reduce thecomplications.
Sometime in the back, I had a patient that had severe fatigue,excessive thirst and experienced the urge to urinate frequently. Ihad to use probing questions and identify specific diseases that somemembers of his family had experienced. Apart from that, I collectedinformation on his medical history, and he revealed the medicationthat he had used in the past. His data was not consistent, and I hadto undertake a diagnostic testing to determine the exact illness thatthe patient was suffering from.
Before recording the diagnostic test, I have to make sure that it isauthenticated by a handwrittensignature or even using the electronic approach too. Besides that,the documents should not match with the tests that were recordedearlier since it is strange for two patients having the same results.In fact, the regulations consider cloning as a misrepresentation ofthe medical information. Hence, I tend to consider all these factorsbefore I record the data to ensure that it can be retrieved when theneed arises.
The electronic medical record tends to be helpful in managing thediagnostic results and ensuring that they can be retrieved easilywhen a need arises. First, the values and test names are stored usingstandardized nomenclature to make them visible. Besides that, thetest reports do have a code interpretation that helps inunderstanding the extent of the problem as well. The system has theability to identify the clinician that is supposed to handle thefollow-up, and I might consult him or her in determining the nextstep to be taken (Hysong et al., 2011). When someone amends therecords, the system often notifies any clinician that is associatedwith diagnosis or the follow-up. Clearly, some of the features thatthe electrical system possesses are essential in managing thediagnostic tests recorded. In the process, it becomes quite easy tofind the required data and use them in research that will find bettermedication for the patient.
In conclusion, dealing with the patients needs accuracy and properknowledge since a slight mistake can have severe complications. Theknowledge of pathophysiology and physical assessment tend to becrucial in identifying the need for diagnostic testing in a patient.The conversation also proves that the medical history, currentmedication or even symptoms can be essential in the long-run. Lastly,the electronic health record system also assists in managing theinformation about the patients.
Geisler, P. R., Hummel, C., & Piebes, S. (2014). EvaluatingEvidence-Informed Clinical Reasoning Proficiency in Oral PracticalExaminations. Athletic Training Education Journal, 9(1),43-48.
Hysong, S. J., Sawhney, M. K., Wilson, L., Sittig, D. F., Esquivel,A., Singh, S., & Singh, H. (2011). Understanding the managementof electronic test result notifications in the outpatient setting.BMC medical informatics and decision making, 11(1), 1.