Clinical Documentation Discussion

Clinical Documentation Discussion

Clinical Documentation Discussion


Question Description
I need support with this Nursing question so I can learn better.

Please respond to

Melanie Shelly

Wk 1 Discussion Post- Melanie Shelly


Building a Health History

Building a health history not only allows you, the advanced practitioner, to get to know vital health related information about your patient, but it also is a key component in the formation of trust, the foundation of a strong

patient-provider relationship (Ball et al., 2019). A health history includes patient identifiers (i.e. name, date of birth and gender), chief complaint or concern, a history of the present illness or issue, past medical history, family

history, social history, and finally, a complete review of body systems (2019, p.6). Common potential barriers to communication such as anxiety, fear, depression and anger can inhibit attempts to build upon or develop a health

history with a patient (2019). As healthcare practitioners, it is important to also recognize cultural differences as potential barriers to communication, treatment and health outcomes (Polster, 2018).When attempting to build a

relationship with a patient from a foreign country or of different cultural beliefs, communication and teaching techniques may need to be altered to enhance the patients understanding and overall comfortability.

New Patient Scenario

A 40-year-old, black, recent immigrant woman from Africa comes into the practice to be evaluated and treated. She currently does not have health insurance. Due to this patient’s lack of insurance, accessibility to healthcare may

be extremely limited (Sullivan, 2019). Prior to obtaining patient history, it may be wise to discuss health care treatment options for the uninsured, such as prescribing generic medications, if medications become necessary (2019).

The conversation can be kept simple until after more health-related information is obtained to further guide the dialogue as necessary.

For this particular patient, you may find benefit in focusing more time initially with her social history. Gathering this information first will allow you as the provider to determine how her cultural beliefs and practices may impact

communication, her beliefs about health and specific treatments as well as dietary preferences and familial or community relationships she has developed (Ball et al., 2019). Once any language barriers are addressed if necessary,

a good initial question may be, “I would like to respect your cultural values and beliefs, in doing so, what do I need to know to best provide you care?” (2019, p.13). When discussing her reason for seeking care, we must also

consider her age, discussing preventative care measures, but also her immigration status, reviewing her immunization history and determine any risk of infectious disease exposure. Additional questions may include, what do you

think has caused this issue or illness? Have you used any home remedies to try and treat this? Would you consider taking prescription medication? Would you prefer the use of alternative treatments such as herbal remedies?

(Sullivan, 2019, p.27). Providing culturally competent care not only enhances the patient experience, but it also improves healthcare provider communication (Polster, 2018, p.33).

In conclusion, the length of time spent with this new patient may have to be adjusted in order to address her cultural beliefs and practices. It is imperative to show respect not only to her as a patient but also to these customs,

this will not only strengthen the foundation of this relationship, but it may also provide necessary insight to her chief complaint. Her lack of insurance may be problematic, especially in terms of preventative screenings such as a

mammogram or blood work, however resources may be available for discounted or free services or community clinics. Although there is a heavy focus on this patient’s social history, the addition of her past medical history,

family history and review of systems should present a clear clinical picture.


Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination An interprofessional approach (9th ed.). Elsevier.

Polster, D. S. (2018). Confronting barriers to improve healthcare literacy and cultural competency in disparate populations. Nursing2018, 48(12), 29–33.….

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F. A. Davis .

Clinical Documentation Discussion

Clinical Documentation Discussion

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.


Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
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