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Medical Coding And Billing Sample

Medical Coding And Billing Sample Certification Questions

4. Which one of the following statements accurately represents the practice known as unbundling?

A. Combination codes are assigned separately in ICD-10-CM. B. Codes that should be grouped into one code are broken into separate codes to maximize physician reimbursement. C. ICD-10-PCS codes are broken into separate codes for congruent assignment. D. Codes listed as separate procedures are assigned individually.

5. Placing a catheter into the aorta or directly into an artery or vein is called

A. brachiocephalic manipulation. B. third order placement. C. selective catheter placement. D. nonselective catheter placement.

6. What ICD-10-CM code would be assigned for a patient with acute tubule-interstitial nephritis?

A. L50.0 B. Z02.6 C. N10 D. B96.2

7. The suffix -sis means

A. inflammation. B. drooping. C. condition. D. process.

8. The concept of meaningful use pertains to

A. medical office protocol and document organization. B. electronic health record implementation. C. resource management in the inpatient setting. D. categorization of patient information.

9. In what CPT code range is Surgical Pathology found?

A. 88400–80499 B. 88000–80299 C. 88300–88309 D. 88515–88598

10. According to the CMS National Physician Fee Schedule, what is the conversion factor for basic life support mileage?

A. $32.4726 B. $34.5741 C. $28.8457 D. $36.0666

11. A patient who was involved in a motor vehicle accident is taken to the hospital by ambulance and admitted to the hospital in critical care. The physician sees the patient for 74 minutes in critical care. The physician leaves to attend to other patients in the ICU and the NICU of the same hospital. Five hours later, the physician returns to the patient and continues to treat the patient in critical care for an additional 30 minutes. The patient spends a total of 104 minutes in critical care. What codes are assigned?

A. 99291, 99292 B. 99292, 99293 C. 99291, 99291 D. 99292, 99292, 99293

12. The prefix endo- means

A. beneath. B. outside of. C. adjacent to. D. within.

13. What is the CPT code for a three-view x-ray of the mandible?

A. 70200 B. 70100 C. 70150 D. 70240

14. Rules of evidence control the

A. amount of evidence that may be admitted during a civil trial. B. processes and procedures for question and answer sessions. C. documents that can be considered during jury trial. D. length of criminal court proceedings, but not civil court proceedings.

15. The ampulla, isthmus, interstitium, and fimbria are examples of

A. implantation sites of ectopic pregnancy. B. incision sites for pacemaker insertion. C. membranes in the abdomen. D. bones in the ankle.

16. Code J9165 is assigned for intravenous diethylstilbestrol diphosphate. According to the code description, what dosage was administered?

A. 20 mg B. 50 mg C. Up to 0.5 mg D. 250 mg

17. Members of the uniformed services, their families and survivors, and retired members and their families qualify for

A. TRICARE. B. OIG Recovery. C. Medicare. D. Medicaid.

18. A patient comes to the emergency room complaining of abdominal pain. She was previously diagnosed with type I diabetes. She also complains of watery eyes, congestion, pressure in the sinuses, and difficulty breathing. Her final diagnoses are right lower quadrant abdominal pain, type I diabetes, acute sinusitis, and asthma. What CPT and ICD-10-CM codes are assigned?

A. 99222, R18.91, E16.9, J01.91, J45.919 B. 99221, R17.41, E17.9, J01.90, J45.909 C. 99221, R10.31, E10.9, J01.90, J45.909 D. 99223, R14.31, E15.9, J01.90, J45.929

19. Under HIPAA, health care facilities must

A. follow up with patients who repeatedly miss scheduled appointments for mandatory services. B. keep records of patients who refill prescriptions more than once within a three-month timeframe. C. maintain a clean, safe working environment. D. choose a privacy officer in accordance with HIPAA policies and procedures.

20. What is the ICD-10-CM code for unspecified acute pericarditis?

A. I30.89 B. I30.9 C. I30 D. I30.79

21. What is the full code description for 25515?

A. Open treatment of radial shaft fracture, includes internal fixation, when performed B. Closed treatment of ulnar shaft fracture; without manipulation C. Closed treatment of radial shaft fracture; without manipulation D. Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex

22. Which of the following anatomical locations would contain the diaphysis?

A. Metatarsal B. Diaphragm C. Septum D. Tibia

23. A patient recently became eligible for health insurance through her employer. Her health insurance is considered to be an 80-20 policy. Under the terms of an 80-20 policy, the insurer pays 80 percent and the insured pays 20 percent of expenses. This 80-20 policy is an example of

A. coinsurance. B. prospective payment. C. capitation. D. case management.

24. The Outpatient Prospective Payment System (OPPS) pays

A. an established rate for outpatient services in specific hospitals. B. a percentage of the national average for the same surgery performed in a different geographic location. C. 65% of the schedule C rate for all surgeries. D. subsidies to contain health care costs in rural facilities.

25. The study of disease is called

A. physiology. B. pathology. C. urology. D. neurology.

26. Superficial injuries such as abrasions or contusions are

A. not coded when associated with more severe injuries of the same site. B. queried to determine if the injuries are confined to the same site. C. coded when associated with more severe injuries of the same site. D. coded only when debridement is performed.

27. Another name for XXY syndrome is

A. Turner’s syndrome. B. Cooley’s anemia. C. Klinefelter syndrome. D. Huntington’s chorea.

28. The method that physicians use to bill for each service or visit individually rather than on a pre-paid basis is called

A. fee-for-service. B. capitation. C. pre-paid care. D. managed care.

29. A physician has a meeting with a pharmaceutical sales representative. During the course of the conversation, the physician reveals the diagnosis and past family, medical, and social history of a patient currently being treated with one of the medications that the sales representative is selling. In this situation, the doctor could be sued for

A. invasion of privacy. B. malfeasance. C. undue harm and fraud. D. malice.

30. A patient is prescribed a medication that narrows the blood vessels and raises her blood pressure. The medication is most likely a

A. tranquilizer. B. cardiogenic. C. vasoconstrictor. D. cardiotonic

31. Physicians typically refer to anatomical locations using directional terms, which are often

A. paired in opposites. B. used primarily by chiropractors. C. used to describe surgical incisions. D. referenced horizontally.

32. The study of tissue disease using macroscopic or microscopic analysis is called

A. immunology. B. histopathology. C. cytopathology. D. microbiology.

33. A physician obtains cells from the bone marrow cavity using a needle and a syringe. How would this procedure be coded?

A. 36575 B. 37328 C. 38220 D. 35092

34. What is Medicare Part D?

A. The component of Medicare Part A that covers outpatient surgeries B. Add-on coverage for prescription drugs provided through insurance companies approved by Medicare C. Supplemental coverage for war veterans and their dependents D. Add-on coverage for dental procedures

35. A female patient is seen for her annual gynecological examination. During the examination, the physician performs a test to detect cervical cancer. This test is called a/an

A. immunoassay test. B. Pap smear. C. carcinoembryonic antigen test. D. mycobacterial culture.

36. A physician is called to the intensive care unit for a patient with second-degree burns sustained on 55% of his body while cooking in the kitchen where he works. The physician sees the patient in the critical care unit for two hours, leaves the unit, and returns later the same day to provide an additional hour of critical care. What ICD-10-CM and CPT codes would be assigned?

A. L91.8, 99291 × 2, 99292 × 4 B. R53.81, 99291, 99293 × 5 C. Z30.09, 99293, 99294 × 2 D. T31.50, 99291, 99292 × 4

37. A change in the tissues and cells within a specific area on or in the body is called a

A. lesion. B. cyst. C. neoplasm. D. tumor.

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Individual Success Plan

NRS-490 Individual Success Plan

Individual Success Plan

REQUIRED PRACTICE HOURS: 100

P R A C T I C E I M M E R S I O N	Complete Contact Information
	Student Information	GCU
	Name:
	E-mail:
	Phone Number:
	Course Faculty Information	GCU
	Name:
	E-mail:
	Phone Number:
	Practicum Mentor Information	Practice Setting
	Name:
	E-mail:
	Phone Number:
	MOU signed & uploaded to Instructor in LoudCloud via Individual Forum	Yes ► ☐	No ► ☐ If no, is an existing Affiliation Agreement on file? _____

ISP Instructions

Use this form to develop your Individual Success Plan (ISP) for NRS-490, the Professional Capstone and Practicum course. An individual success plan maps out what you, the RN-to-BSN student, needs to accomplish in order to be successful as you work through this course and complete your overall program of study. You will also share this with your mentor at the beginning and end of this course so that he or she will know what you need to accomplish.

Application-based learning assignments are listed in the course syllabus with a Practice Portfolio Statement requirement element noted within the assignment itself. In order for you to successfully complete and graduate from the RN-to-BSN Program you must meet the following programmatic requirements: (1) completion of 100 practice immersion hours, and (2) completion of work associated with all program competencies.

In this ISP, you will identify all of the objectives, tasks, and/or assignments relating to the 100 practice immersion hours you need to complete by the end of this course. Specify the dates by which you will complete each tasks and/or assignments. Your plan should include a self-assessment of how you met all applicable GCU RN-to-BSN Domains & Competencies (see Appendix A).

ALL course assignments listing a “Practice Hours Portfolio” statement must be included in the ISP and are worth and recorded here as approximately 10 hours each. Actual clock hours must be recorded on this time log.

General Requirements

Use the following information to ensure successful completion of each assignment as it pertains to deliverables due in this course:

· Use the Individual Success Plan to develop a personal plan for completing your practice immersion hours and self-assess how you will meet the GCU RN-to-BSN University Mission Critical Competencies and the Programmatic Domains & Competencies (Appendix A) related to that course.

Show all of the major deliverables in the course, the topic/course objectives that apply to each deliverable, and lastly, align each deliverable to the applicable University Mission Critical Competencies and the course-specific Domains and Competencies (Appendix A).

Completing your ISP does not earn practice hours, nor does telephone conference time, or time spent with your mentor.

· Within the Individual Success Plan, ensure you identify all course assignments which may include the following: Memorandums of Understanding (MOU)(if Affiliation Agreement is not required); comprehensive log of practice immersion hours applied to baccalaureate level learning outcomes; evaluations from faculty and mentors; your evaluations of your mentor; scholarly activity report; competency self-assessment (part of your ISP); reflective journal (Submitted in Week 10 but covering all weeks in the course); course goals and plan for how competencies and practice immersion hours will be met; and both faculty and mentor approvals of course goals and documented practice immersion hours.

Application-based Learning Course Assignments	List of Current Course Objectives	Number of Clock Hours Associated with Each Assignment	Assignment Date Due	Self-Assessment: GCU RN-to-BSN University Mission Critical Competencies and Programmatic Domains & Competencies (see Appendix A)	Date Assignment Completed

By typing in his/her signature below, the student agrees to have read, understood, and be accountable for the instructions, assignments, and hours shown above and that all questions have been satisfactorily answered by the faculty and/or program director.

Mentors will sign upon initial receipt and at the end of the course to confirm that assignments have been complete with your guidance.

Student Signature
Name:
Date:
Mentor Signature [Upon Initiation of Course]
Name:
Date:
Mentor Signature [Upon Completion of Course]
Name:
Date:

cid:D7D4B297-EEAE-4174-AD01-F87097282051@canyon.com

APPENDIX A:

GCU RN-to-BSN Domains & Competencies

A. University’s Mission Critical Competencies

How does this Individual Success Plan support the GCU Mission?

MC1: Effective Communication: Therapeutic communication is central to baccalaureate nursing practice. Students gain an understanding of their ethical responsibility and how verbal and written communication affects others intellectually and emotionally. Students begin to use nursing terminology and taxonomies within the practice of professional and therapeutic communication. Courses require students to write scholarly papers, prepare presentations, develop persuasive arguments, and engage in discussion that is clear, assertive, and respectful.

MC2: Critical Thinking: Courses require students to use critical thinking skills by analyzing, synthesizing, and evaluating scientific evidence needed to improve patient outcomes and professional practice.

MC3: Christian Worldview: Students will apply a Christian worldview within a global society and examine ethical issues from the framework of a clearly articulated system of professional values. Students will engage in discussion of values-based decisions made from a Christian perspective.

MC4: Global Awareness, Perspectives, and Ethics: The concept of global citizenship is introduced to baccalaureate students in the foundational curriculum. Some courses will focus on the human experience across the world health continuum. The World Health Organization (WHO) definitions of health, health disparities, and determinants of health are foundational to nursing practice.

MC5: Leadership: Students will apply a Christian worldview within a global society and examine ethical issues from the framework of a clearly articulated system of professional values. Students will engage in discussion of values-based decisions made from a Christian perspective.

B. Domains and Competencies

How does this Individual Success Plan support the Program Domains and Competencies?

Domain 1: Professional Role

Graduates of Grand Canyon University’s RN-BSN program will be able to incorporate professional values to advance the nursing profession through leadership skills, political involvement, and life-long learning.

Competencies:

1.1: Exemplify professionalism in diverse health care settings.

1.2: Manage patient care within the changing environment of the health care system.

1.3: Exercise professional nursing leadership and management roles in the promotion of patient safety and quality care.

1.4: Participate in health care policy development to influence nursing practice and health care.

1.5: Advocate for autonomy and social justice for individuals and diverse populations.

Domain 2: Theoretical Foundations of Nursing Practice

Graduates of Grand Canyon University’s RN-BSN program will have acquired a body of nursing knowledge built on a theoretical foundation of liberal arts, science, and nursing concepts that will guide professional practice.

Competencies:

2.1: Incorporate liberal arts and science studies into nursing knowledge.

2.2: Comprehend nursing concepts and health theories.

2.3: Understand and value the processes of critical thinking, ethical reasoning, and decision making.

Domain 3: Nursing Practice

Graduates of Grand Canyon University’s RN-BSN program will be able to utilize the nursing process to provide safe quality care based on nursing best practices.

Competencies:

3.1: Utilize the nursing process to provide safe and effective care for patients across the health-illness continuum: promoting, maintaining, and restoring health; preventing disease; and facilitating a peaceful death.

3.2: Implement patient care decisions based on evidence-based practice.

3.3: Provide individualized education to diverse patient populations in a variety of health care settings.

3.4: Demonstrate professional standards of practice.

Domain 4: Communication/Informatics

Graduates of Grand Canyon University’s RN-BSN program will be able to manage information and technology to provide safe quality care in a variety of settings. In addition, graduates will be able to communicate therapeutically and professionally to produce positive working relationships with patients and health care team members.

Competencies:

4.1: Utilize patient care technology and information management systems.

4.2: Communicate therapeutically with patients.

4.3: Professionally communicate and collaborate with the interdisciplinary health care teams to provide safe and effective care.

Domain 5: Holistic Patient Care

Graduates of Grand Canyon University’s RN-BSN program will be able to provide holistic individualized care that is sensitive to cultural and spiritual aspects of the human experience.

Competencies:

5.1: Understand the human experience across the health-illness continuum.

5.2: Assess for the spiritual needs and provide appropriate interventions for individuals, families, and groups.

5.3: Provide culturally sensitive care.

5.4: Preserve the integrity and human dignity in the care of all patients.

NRS

–

490 Individual Success Plan

REQUIRED PRACTICE HOURS

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http://www.jointcommission.org/topics/speakup_brochures.aspx

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

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Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including 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 the 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 Loud-cloud 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 over-utilization of direct quotes in DQs and assignments at the Master’s 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 Lopes Write, 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 Loud-cloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is a 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

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. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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Fundamentals RUA National Patient

NR 224 Fundamentals RUA National Patient Safety Goals

Assignment Guidelines NR224 Fundamentals – Skills

Required Uniform Assignment: National Patient Safety Goals

PURPOSE This exercise is designed to increase the students’ awareness of the National Patient Safety Goals developed by The Joint Commission. Specifically, this assignment will introduce the Speak Up Initiatives, an award- winning patient safety program designed to help patients promote their own safety by proactively taking charge of their healthcare.

COURSE OUTCOMES This assignment enables the student to meet the following course outcomes.

CO #2: Apply the concepts of health promotion and illness prevention in the laboratory setting. (PO #2)

CO #8: Explain the rationale for selected nursing interventions based upon current nursing literature. (PO #8)

DUE DATE Week 6

Campus: As directed by your faculty member

Online: As directed by your faculty member

POINTS 50 points

REQUIREMENTS 1. Select a Speak Up brochure developed by The Joint Commission. Follow this link to the proper

website: http://www.jointcommission.org/topics/speakup_brochures.aspx.

2. Write a short paper reviewing the brochure. Use the Grading Criteria (below) to structure your critique, and include current nursing or healthcare research to support your critique.

a. The length of the paper is to be no greater than three pages, double spaced, excluding title page and reference page. Extra pages will not be read and will not count toward your grade.

3. This assignment will be graded on quality of information presented, use of citations, and use of Standard English grammar, sentence structure, and organization based on the required components.

4. Create the review using Microsoft Word 2007 (a part of Microsoft Office 2007), the required format for all Chamberlain documents. You can tell that the document is saved as a MS Word 2007 document because it will end in “.docx.”

5. Any questions about this paper may be discussed in the weekly Q & A Forum in your online course or directly with your faculty member if you are taking NR224 on campus.

6. APA format is required with both a title page and reference page. Use the required components of the review as Level 1 headers (upper- and lowercase, bold, centered).

a. Introduction b. Summary of Brochure c. Evaluation of Brochure d. Conclusion

PREPARING THE PAPER The following are the best practices in preparing this paper.

1) Read the brochure carefully and take notes. Highlighting important points has been helpful to many students.

Assignment Guidelines NR224 Fundamentals – Skills

NR224 Safety Goals RUA.docx Revised 06/14/2016 BME 2

2) Title page: Include title of your paper, your name, Chamberlain College of Nursing, NR224 Fundamentals—Skills, faculty name, and the date. Center all items between the left and right margins, beginning approximately 3 inches from the top margin.

NOTE: This style of cover page is required by the college and is a variance of APA formatting.

3) Use the CCN library or online library to find current nursing research that supports your findings.

4) The brochure you select must be properly cited in the body of your paper and on the reference list.

DIRECTIONS AND GRADING CRITERIA

Category Points % Description

Introduction 3 6 This first part of your paper should be one paragraph that includes the brochure title, date published, and your understanding of who the information would benefit.

Summary of the brochure’s recommendations

10 20 Summary of brochure must include 1. main topics discussed; and 2. how communication between patients and healthcare providers

is encouraged.

Evaluation of the brochure

20 40 Critique the brochure. Include a full one- to two-page critique that answers all of the following questions.

1. What was done well, and what could have been improved in the brochure?

2. Why did this topic interest you? 3. Was the information provided in the brochure beneficial? Could

you incorporate it in your patient education? 4. Was the information presented clearly? 5. Did current nursing or healthcare related research support the

information presented in the brochure? 6. What population or individuals does this article apply to (i.e.,

who will benefit the most from this brochure)? Who else can use this information?

7. Will this information increase patient safety? Defend your answer.

Conclusion 5 10 An effective conclusion identifies the main ideas and major support points from the body of your report. Minor details are left out. Summarize the benefits of following the brochure’s advice to a person at risk.

Clarity of writing 10 20 Use Standard English grammar and sentence structure. No spelling or typographical errors (typos) are present. The paper is organized around required components, using appropriate headers.

APA format 2 4 All information taken from another source, even if summarized, must be cited in the paper and listed in the references using (APA sixth ed.) format.

1. Document setup 2. Title and reference pages. 3. Citations in the text and reference page.

Total 50 100%

Assignment Guidelines NR224: Fundamentals-Skills

NR224 Safety Goals RUA.docx Revised 06/14/2016 BME 3

GRADING RUBRIC

Assignment Criteria Outstanding or Highest Level of Performance

A (92–100%)

Very Good or High Level of Performance B (84–91%)

Competent or Satisfactory Level of Performance

C (76–83%)

Poor, Failing or Unsatisfactory Level of Performance

F (0–75%)

Introduction

3 points

Introduction provides a full and complete identification of the brochure, including the brochure title, date published, and understanding of who the information would benefit.

3 points

Partial identification of required elements OR introduction contains no required elements OR no introduction

0–2 points

Summary of the article 10 points

Summary is complete and thoroughly covers all required elements.

10 points

Summary is complete and is missing no more than one required element.

9 points

Summary is complete and is missing no more than two required elements.

8 points

Summary is incomplete or not included and is missing more than one required element.

0–7 points

Evaluation of the Article

20 points

Critique of article demonstrates critical thinking and answers all required questions and supported findings with current nursing research.

19–20 points

Critique demonstrates basic understanding of article, answers all but one of the required questions, and/or does not support findings with current research.

17–18 points

Critique demonstrates basic understanding of article, answers all but two or three of the required questions, and/or does not support findings with current research.

16 points

The critique of the article is poor, lacks critical or original thinking, and fails to answer two or more questions

0–15 points

Conclusion

5 points

Original explanation is well evidenced and developed.

5 points

Original explanation is present and well evidenced, yet not well developed.

4.5 points

Original explanation is present, though not well evidenced or developed.

4 points

Conclusion is omitted OR no original explanation is present in conclusion.

0–3 points

Clarity of writing

10 points

Paper has excellent use of Standard English, showing original thought, has no spelling or grammar errors, and is well organized.

10 points

Paper has some evidence of own expression and competently uses language, no more than two spelling or grammar errors, and is well organized.

9 points

Paper has some evidence of own expression and competently uses language, no more than four spelling or grammar errors, and is well organized.

8 points

Language needs development. There are five or more spelling and/or grammar errors, and paper is poorly organized.

0–7 points

APA format

2 points

Paper correctly follows APA format with no more than two types of errors.

2 points

Paper has three to five errors in APA format, grammar, spelling, and syntax and/or one–two citations are missing.

1 point

APA, grammar, spelling and/or punctuation contain multiple errors and/or many citations are missing.

0 points

Total Points Possible = 50 points

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NR 224 Fundamentals RUA National Patient Safety Goals

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6512 WK 11 Assignment

Assignment: Ethical Concerns

As an advanced practice nurse, you will run into situations where a patient’s wishes about his or her health conflict with evidence, your own experience, or a family’s wishes. This may create an ethical dilemma. What do you do when these situations occur?

In this Assignment, you will explore evidence-based practice guidelines and ethical considerations for specific scenarios.

Scenario 1:

The parents of a 5-year-old boy have accompanied their son for his required physical examination before starting kindergarten. His parents are opposed to him receiving any vaccines.

Scenario 2:

A 49-year-old woman with advanced stage cancer has been admitted to the emergency room with cardiac arrest. Her husband and one of her children accompanied the ambulance.

Scenario 3:

A 27-year-old man with Crohn’s disease has been admitted to the emergency room with an extreme flare-up of his condition. He explains that he has not been able to afford his medications for the last few months and is concerned about the costs he may incur for treatment.

Scenario 4:

A single mother has accompanied her two daughters, aged 15 and 13, to a women’s health clinic and has requested that the girls receive a pelvic examination and be put on birth control. The girls have consented to the exam but seem unsettled.

Scenario 5:

A 17-year-old boy has come in for a check-up after a head injury during a football game. He has indicated that he would like to be able to play in the next game, which is in 3 days.

Scenario 6:

A 12-year-old girl has come in for a routine check-up and has not yet received the HPV vaccine. Her family is very religious and believes that the vaccine would encourage premarital sexual activity.

Scenario 7:

A 57-year-old man who was diagnosed with motor neuron disease 2 years ago is experiencing a rapid decline in his condition. He prefers to be admitted to the in-patient unit at a hospice to receive end-of-life care, but his wife wants him to remain at home.

To prepare:

· Select one scenarios, and reflect on the material presented throughout this course.

· What necessary information would need to be obtained about the patient through health assessments and diagnostic tests?

· Consider how you would respond as an advanced practice nurse. Review evidence-based practice guidelines and ethical considerations applicable to the scenarios you selected.

To complete:

Write a detailed one-page narrative (not a formal paper) explaining the health assessment information required for a diagnosis of your selected patient (include the scenario number). Explain how you would respond to the scenario as an advanced practice nurse using evidence-based practice guidelines and applying ethical considerations. Justify your response using at least 3 different references from current evidence based literature.

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PICOT Question And Literature Search

The first step of the evidence‐based practice process is to evaluate a nursing practice environment to identify a nursing problem in the clinical area. When a nursing problem is discovered, the nurse researcher develops a clinical guiding question to address that nursing practice problem.

For this assignment, you will create a clinical guiding question know as a PICOT question. The PICOT question must be relevant to a nursing practice problem. To support your PICOT question, identify six supporting peer‐revised research articles, as indicated below. The PICOT question and six peer‐reviewed research articles you choose will be utilized for subsequent assignments.

Use the “Literature Evaluation Table” to complete this assignment.

Select a nursing practice problem of interest to use as the focus of your research (use hypertension as a topic/problem). Start with the patient population and identify a clinical problem or issue that arises from the patient population. In 200–250 words, provide a summary of the clinical issue.
Following the PICOT format, write a PICOT question in your selected nursing practice problem area of interest. The PICOT question should be applicable to your proposed capstone project (the project students must complete during their final course in the RN‐BSN program of study).
The PICOT question will provide a framework for your capstone project.
Conduct a literature search to locate six research articles focused on your selected nursing practice problem of interest. This literature search should include three quantitative and three qualitative peer‐reviewed research articles to support your nursing practice problem.

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Disorders Of Brain Function

How Is The Concept “Disorders Of Brain Function” Related To Fred’s Presenting Symptoms?

Chapter 20

Fifty-four–year-old Fred is complaining of a headache that started about 2 weeks ago. For the past 2 days, the headache has increased in severity, and he is photophobic and has uncial rigidity and projectile vomiting. CT scan results show an arteriovenous malformation in the basal artery and a small hemorrhagic bleed in the middle meningeal artery.

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Study Guide Questions

Chapter 8, Page 218

#1 Identify a healthcare operating issue that could benefit from each of the analytical techniques: a. Descriptive

b. Predictive

c. Prescriptive

· Chapter 10, page 276 and 277

1. What are the drivers of the healthcare industry’s focus on patient satisfaction and on employing resources in an effective manner?

2. What are the differences between Lean and Six Sigma? The similarities? Would you like to see both applied in your organization? Why or why not?

#2 (no need to answer the last sub-question regarding having both applied to your organization)

· Chapter 11, Page 319

#2 Which process improvement tool can have the most powerful impact, and why?

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Enhancing Quality And Safety

For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.
Health care organizations and professionals strive to create safe environments for patients however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).
The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.
You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.
- Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
Competency 2: Analyze factors that lead to patient safety risks.
- Explain factors leading to a specific patient-safety risk focusing on medication administration.
Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
- Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
- Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
- Communicate using writing that is clear, logical, and professional with correct grammar and spelling using current APA style.
References
Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from /orders/www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
Professional Context
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
Scenario
Consider the hospital-acquired conditions that are not reimbursed under Medicare/Medicaid, some of which are specific safety issues such as infections, falls, medication errors, and other concerns that could have been prevented or alleviated with the use of evidence-based guidelines.
Choose a specific condition of interest surrounding a medication administration safety risk and incorporate evidence-based strategies to support communication and ensure safe and effective care.
For this assessment:
Analyze a current issue or experience in clinical practice surrounding a medication administration safety risk and identify a quality improvement (QI) initiative in the health care setting.
Instructions
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.
Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.
Explain factors leading to a specific patient-safety risk focusing on medication administration.
Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.
Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Additional Requirements
Length of submission: 3-5 pages, plus title and reference pages.
Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: References and citations are formatted according to current APA style.
Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final Capstone course.
Scoring Guide
Use the scoring guide to understand how your assessment will be evaluated.

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Week 7 Shadow Health

Name:

Focused Exam: Chest Pain

Subjective

Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentation, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template – Focused Exam_Chest_Pain – NURS 6512”

S. CC: “Chest pain”

HPI: The patient is a 58-year-old white American male who reports pain in the mid chest every no-and-then for the past month. The patient states the pain “feels like tightness than sharp pain” Patient reports pain is in the middle of the chest over the heart and has occurred three times in the past month and goes away after a couple of minutes. Patient rates pain six out of ten in terms of intensity but is currently a zero intensity. The pain is aggravated by physical activity and relieved by rest. The denied taking any medication to relieve the pain.

PMH: Positive for high blood pressure and high cholesterol, checks BP during check-up visits to the doctor every 6months, last labs were drawn 3 months ago. Believes he takes Lisinopril 20mg daily and Atorvastatin 20mg daily for high BP and high cholesterol, respectively. Takes 1200mg fish oil daily, Ibuprofen or Tylenol for pain occasionally, allergy to Codeine causes nausea and vomiting. Denies previous hospitalizations or surgeries.

FH: Dad died at 75 from colon cancer but was overweight and had high blood pressure and high cholesterol prior to death. Mom is 80 and has type 2 diabetes and high blood pressure. Brother died from a car accident at 24 and sister has diabetes and hypertension.

SH: Negative for tobacco or drug use, consumes moderate amount of alcohol (2 to 3 beers on a weekend), lives with wife and kids, has “a couple of good friends I can rely on”, no stress from work. Gained 20 pounds in the last 2 years, denies regular exercise in the last 2 years, typical breakfast is instant shakes or granola bar, lunch is subs or a salad, dinner is grilled meats and vegetables, drinks at least 4 glasses of water daily.

ROS General- Anxious about chest pain, denies stress, sleeps 6-7 hours a night, negative for fever, chills, fatigue, night sweats, dizziness, light-headedness.

Cardiovascular- Denies palpitations, heart murmur, blood clots, rheumatic fever, bleeding and bruising easily, reports EKG 3 months ago and stress test yearly with normal results Gastrointestinal-Negative for diarrhea, abdominal pain, constipation, flatus, bloating, heartburn, nausea, vomiting, indigestion. Pulmonary- Negative for cough, dyspnea, shortness of breath.

Document: Provider Notes – NURS 6512

This study source was downloaded by 100000822789681 from CourseHero.com on 04-15-2021 18:16:01 GMT -05:00

/file/78222222/Focused-Exam-Chest-Paindocx/

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Objective

VS: BP 146/90; P 104; R 19; T 36.7; 02 98% Wt 197lbs; Ht 5ft 11 inches

General- Patient appears worried and anxious

Cardiovascular- No jugular vein distention, venous pressure 4cm or less above the sternal angle, chest symmetrical with no visible abnormalities, capillary refill <3sec to bilateral fingers and toes, S1, S2 and S3 heart sounds audible with gallops, thrill noted to right carotid artery with 3+ amplitude, 2+ amplitude and no thrill other arteries, no bruits to abdominal aorta, or abdominal or lower extremity arteries, PMI is in the 5th inter-costal space displaced laterally, brisk and tapping. No cyanosis, clubbing, noted, no lower extremity edema is noted.

Gastrointestinal–The abdomen is rounded and symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; no tenderness, masses, no abnormal observations to abdomen, no abnormality to liver, spleen, kidneys on palpation and percussion. No tenting.

Pulmonary- Positive lung sounds to all areas bilaterally with fine crackles noted to bilateral lower lobes.

Diagnostic results: EKG: Normal sinus rhythm with no ST elevation.

Document: Provider Notes – NURS 6512

This study source was downloaded by 100000822789681 from CourseHero.com on 04-15-2021 18:16:01 GMT -05:00

/file/78222222/Focused-Exam-Chest-Paindocx/

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Assessment

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis

should be at the top of the list (#1).

Differential Diagnosis:

1) Angina from Coronary artery disease is caused by damage to the major vessels of the heart usually from plaque buildup and is characterized by a history of cardiovascular disease (CVD), it is common in females ≥65 years or males ≥55 years. In CAD, there could be no pain or there could be pain that increases with exercise and the pain is not reproducible by palpation. The pain in CAD usually has a duration of 1–60 minutes and is located in the substernal area (Harskamp et al., 2019). CAD is high in the list of differential diagnoses because the patient in this case study is a 58 year old male, had pain for only a couple of minutes each time, the pain was not reproducible by palpation, the patient’s pain was also in the substernal area and was described as feeling more like “chest tightness”. All the above and the fact that the patient’s pain also increased with physical activity and the patient’s pain has been intermittent makes CAD the primary diagnosis.

2) Acute coronary syndrome results from the sudden blockage of coronary artery leading to unstable angina or myocardial infarction depending on the location of the blockage and the percentage of the coronary artery that is blocked. Acute coronary syndrome is characterized by the radiation of pain, the presence of nausea/sweating, abnormal EKG, and a history of coronary artery disease (CAD) (Harskamp et al., 2019). Acute coronary syndrome is not the primary diagnosis because the patient did not have a history of CAD, there was no radiation of pain and no nausea/sweating.

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

Document: Provider Notes – NURS 6512

This study source was downloaded by 100000822789681 from CourseHero.com on 04-15-2021 18:16:01 GMT -05:00

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References

Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W., & van Weert, H. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ open, 9(2), e027081. /orders/doi.org/10.1136/bmjopen-2018-027081

Document: Provider Notes – NURS 6512

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