June 9th, 2012
By guest bloggers Lee Houston RN BSN and Pat Iyer RN MSN LNCC
9 Advantages of Reviewing Medical Records Using Adobe Acrobat
This blog post refers to using a computer monitor and Adobe Acrobat to review medical records that have been saved as PDFs.
1. It’s more cost effective. Consider the costs of a copier, a scanner, toner, paper, postage, and maintenance of a copier machine, compared to the cost of scanning records and recording a disk.
2. Electronic files can be sent or stored on a document sharing site, making them accessible to many people.
3. It is easier to store records that are scanned and saved on a CD.
4. Electronic medical records are much more portable.
5. Electronic records can be searched using Adobe Acrobat.
6. You can bookmark pages using Adobe acrobat as well as add comments.
7. You can combine PDF files using Adobe Acrobat, and then number them using a Bates stamping system such as the one that is part of Case Map
8. You can copy and paste sections of a medical record without having to retype or transcribe them.
9. You can electronically reorganize pages within a file.
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February 25th, 2012
There are days, especially when I am with students, when I feel my life has been divinely led. Tonight was on of those evenings. My clinical setting is a SNF for medically fragile children- one of a handful in the country. Kids there have trachs, g tubes, j tubes and soon will start taking vents as well. The main diagnosis is Cerebral palsy, but there are also children with genetic disorders, severe TBI, and near drowning.
I got into my part time job as a clinical instructor by accident- one of my previous students told me that they needed an instructor for this setting, and knew that I would be a perfect fit. After all, I had 7 years of experience of working with special needs kids and adults.
I had never thought before of wanting to be a nursing instructor. Even though I always had students in my previous jobs, they were always fit into an already tight schedule and I would feel resentful- how would I do my own job, when I am making sure they were taken care of?
So, fast forward to the present time and my joy of being with students. I consider myself very fortunate to be with the students in this setting and tell them regularly it is my honor to be their instructor. I tell them that working with these children is a spiritual experience and they will never be the same.
I talk a lot to the students about the spiritual side of nursing- the part that leaves us so often when we are busy and stressed. I tell them my definition of spiritual care- which is bearing witness- just being there and not necessarily needing to provide anything except a smile, touch, or ear.
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February 13th, 2012
As Legal Nurse Consultants we may be faced with reviewing charts where any number of these issues have occurred. These are problems that when patients and families face them, lead to unpleasant discussions, many times very emotional outcomes, and frequently lead them to believe that someone needs to be sued because the outcome was not what they desired. An attorney may ask you to give your opinion on whether the right decision was made. Are we able to determine what the right ethical decision is? No, because what may seem ethical to me may not be ethical to someone else. However, we can determine whether the health care provider did all that they could to facilitate communication so that the patient and their family were able to make an informed decision.
What are some ethical issues that one may run into with the End Stage Renal Disease (ESRD) patient population?
1. Starting Dialysis
2. Withdrawal of Dialysis
4. Do Not Resuscitate (DNR)
I will give you some scenarios; each I have had experience with, and each has its own set of ethical issues. Read the rest of this entry »