We thank the 14 brain injury patients who are members of the "Amazing" Brain Injury Survivor Support Group in Framingham, MA or accessing outpatient services through Spaulding Rehabilitation Hospital for participating in the study that led to this paper. Funding and other support for the study were provided by the Brain Injury Association of Massachusetts, the Statewide Health Injury Program of the Massachusetts Rehabilitation Commission, and the Agency for Healthcare Research in Quality and the Schneider Institutes for Health Policy at the Heller School for Social Policy and Management, Brandeis University, through a doctoral training fellowship in health services research and policy analysis.

<ol>
	<li>Berland, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+view+from+the+other+side+Patients,+doctors,+and+the+power+of+a+camera.">The view from the other side Patients, doctors, and the power of a camera.</a> The New England Journal of Medicine. 357, 2533-2536 (2007).</li><li>Boyle, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+decade+of+the+brain.">The decade of the brain.</a> The Park Ridge Center for Health, Faith, and Ethics [Internet]. , (1998).</li><li>Chalfen, R., Rich, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Applying+visual+research:+patients+teaching+physicians+through+visual+illness+narratives.">Applying visual research: patients teaching physicians through visual illness narratives.</a> Visual Anthropology Review. 20, 17-30 (2004).</li><li>Chamberlain, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+experience+of+surviving+traumatic+brain+injury.">The experience of surviving traumatic brain injury.</a> Jurnal of Advanced Nursing. 54, 407-417 (2006).</li><li>Chilingerian, J. A., Herzlinger, R. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Who+has+star+quality?.">Who has star quality?.</a> Consumer-driven health care: Implications for providers, payers, and policy-makers. , 443-453 (2004).</li><li>Chilingerian, J. A., Jones, R., Jenkins, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+discipline+of+strategic+thinking+in+health+care.">The discipline of strategic thinking in health care.</a> Managing and leading in the allied health professions. , 191-226 (2006).</li><li>Entwistle, V., Tritter, J. Q., Calnan, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Researching+experiences+of+cancer:+the+importance+of+methodology.">Researching experiences of cancer: the importance of methodology.</a> European Journal of Cancer Care. 11, 232-2337 (2002).</li><li>Guillemin, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Understanding+illness:+Using+drawings+as+a+research+method.">Understanding illness: Using drawings as a research method.</a> Qualitative Health Research. 14, 272-289 (2004).</li><li>Hagen, C., Malkmus, D., Durham, P., Stenderup, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Ranchos Los Amigos cognitive levels of functioning scale (revised). , (1997).</li><li>Institute of Medicine. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Crossing the quality chasm: A new health system for the 21st century. , (2001).</li><li>Kim, W. C., Mauborgne, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fair+process:+Managing+in+the+knowledge+economy.">Fair process: Managing in the knowledge economy.</a> Harvard Business Review. 75, 65-75 (1997).</li><li>Langlois, J. A., Rutland-Brown, W., Thomas, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+incidence+of+traumatic+brain+injury+among+children+in+the+United+States+-+Differences+by+race.">The incidence of traumatic brain injury among children in the United States - Differences by race.</a> Journal of Head Trauma Rehabilitation. 20, 229-238 (2005).</li><li>Langlois, J. A., Rutland-Brown, W., Thomas, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Traumatic brain injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. , (2004).</li><li>Levin, T., Scott, B. M., Borders, B., Hurt, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aphasia+talks:+Photography+as+a+means+of+communication,+self-expression+and+empowerment+in+persons+with+aphasia.">Aphasia talks: Photography as a means of communication, self-expression and empowerment in persons with aphasia.</a> Topics in Stroke Rehabilitation. 14, 72-84 (2007).</li><li>Lorenz, L. S., Berger, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Brain+injury+survivors:+Narratives+of+rehabilitation+and+healing.">Brain injury survivors: Narratives of rehabilitation and healing.</a> Disability in Society. , (2010).</li><li>Lorenz, L. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Discovering+a+new+identity+after+brain+injury.">Discovering a new identity after brain injury.</a> Sociology of Health &#38; Illness. 32, 862-879 (2010).</li><li>Lorenz, L. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Visual+metaphors+of+living+with+brain+injury:+Exploring+and+communicating+lived+experience+with+an+invisible+injury.">Visual metaphors of living with brain injury: Exploring and communicating lived experience with an invisible injury.</a> Visual Studies. 25, 210-223 (2010).</li><li>Lorenz, L. S., Kolb, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Involving+the+public+through+participatory+visual+methods.">Involving the public through participatory visual methods.</a> Health Expectations. 12, 262-274 (2009).</li><li>Lorenz, L. S., Kolb, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Doing+your+own+PhotoVoice+project:+A+guide.">Doing your own PhotoVoice project: A guide.</a> Brainline [Internet]. , (2009).</li><li>Lorenz, L. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+fair+process+to+cross+the+quality+and+health+care+chasm:+Eliciting+the+perspective+of+traumatic+brain+injury+survivors.">Using fair process to cross the quality and health care chasm: Eliciting the perspective of traumatic brain injury survivors.</a> , (2007).</li><li>National Institutes of Health. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rehabilitation+of+persons+with+traumatic+brain+injury.">Rehabilitation of persons with traumatic brain injury.</a> , (1998).</li><li>Oakley, A., Bendelow, G., Barnes, J., Buchanan, M., Husain, O. A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Health+and+cancer+prevention:+Knowledge+and+beliefs+of+children+and+young+people.">Health and cancer prevention: Knowledge and beliefs of children and young people.</a> British Medical Journal. 310, 1029-1033 (1995).</li><li>Prigatano, G. P., Schacter, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Awareness of deficit after brain injury: Clinical and theoretical issues. , (1991).</li><li>Prigatano, G. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Work,+love,+and+play+after+traumatic+brain+injury.">Work, love, and play after traumatic brain injury.</a> Bulletin of the Menninger Clinic. 53, 414-431 (1989).</li><li>Prior, L. B. e. l. i. e. f. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=knowledge+and+expertise:+the+emergence+of+the+lay+expert+in+medical+sociology.">knowledge and expertise: the emergence of the lay expert in medical sociology.</a> Sociology of Health &#38; Illness. 25, 41-57 (2003).</li><li>Radley, A., Taylor, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Images+of+recovery:+a+photo-elicitation+study+on+the+hospital+ward.">Images of recovery: a photo-elicitation study on the hospital ward.</a> Qualitative Health Research. 13, 77-99 (2003).</li><li>Heyden, L. B. V. a. n. d. e. r., Blondel, C., Carlock, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fair+process:+Striving+for+justice+in+family+business+family+business.">Fair process: Striving for justice in family business family business.</a> Family Business Review. 18, 1-21 (2005).</li><li>Rich, M., Lamola, S., Gordon, J., Chalfen, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Video+intervention/prevention+assessment:+A+patient-centered+methodology+for+understanding+the+adolescent+illness+experience.">Video intervention/prevention assessment: A patient-centered methodology for understanding the adolescent illness experience.</a> Journal of Adolescent Health. 27, 155-165 (2000).</li><li>Sherry, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> If I only had a brain: Deconstructing brain injury. , (2006).</li><li>Wang, C., Burris, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Photovoice:+Concept,+methodology,+and+use+for+participatory+needs+assessment.">Photovoice: Concept, methodology, and use for participatory needs assessment.</a> Health Education &#38; Behavior. 24, 369-387 (1997).</li><li>Yin, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Case study research, design and methods. , (2003).</li></ol>

The first author provides trainings in photovoice and photo-elicitation through medical schools and other educational venues. The second author has nothing to disclose.

Respondents become partners and play the role of "co-expert" role in the clinical setting when their lived experience is sought only the patient can really know what it is like to live with brain injury and experience related care. Further, the health care goal for many brain injury survivors appears to be healing, not recovery. Recovery implies a desire to return to a pre-injury status. Newly injured patients may be hoping to recover from their injuries, but long-term survivors have accepted that they will not be able to return to their prior status. They see healing as cognitive, physical, emotional, and even spiritual (Lorenz 2010a). They perceive that they continue to progress over time, even many years after their injury. Discussing photographs of their lives may help patients and clinicians to identify person-centered areas of concern and recognize and appreciate patient progress over time.
Applying fair process to clinical care means the patients are deeply engaged, exploring the way that their experience can be improved, understanding the rationale for all clinical decisions, and accepting their role and responsibility. Fair process activates patient motivation to adhere to rehabilitation strategies and take action to progress in their healing. When providers apply fair process to clinical care, patient and provider expectations and goals may be better aligned. The photograph becomes the focus of the interaction and engages the professional as well as the patient in exploring experience and building relationships. The therapeutic relationship may be improved. Further, according to the Kim and Mauborgne model, resulting attitude and behavior changes could lead to improved outcomes. 
With fair process, power in the clinical interaction may become more balanced as patients feel that they are being heard. Discuss photographs and their meaning can help patients to become part of the solution, not just the problem. Using cameras is not the only way to achieve fair process, and it is not an approach for every patient or every clinician. It is a tool and methodology to engage patients, improve communication under difficult circumstances, and achieve person-centered care.

using visual and narrative methods to achieve fair process in clinical care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

Watch this Scientific Journal Video about Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care at JoVE.com

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

using-visual-narrative-methods-to-achieve-fair-process-clinical

Research

Education

JoVE Journal

JoVE Core

Nursing

Medicine

Unit 1

Ethical and Legal Aspects in Nursing

Healthcare Delivery Systems

SCIENTISTS IN ACTION

23.4K Views.  Brandeis University. This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

Video: Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

A Familiarization Protocol Facilitates the Participation of Children with ASD in Electrophysiological Research

This paper includes a detailed description of a familiarization protocol, which is used as an integral component of a larger research protocol to collect electroencephalography (EEG) data and Event-Related Potentials (ERPs). At present, the systems available for the collection of high-quality EEG/ERP data make significant demands on children with developmental disabilities, such as those with an Autism Spectrum Disorder (ASD). Children with ASD may have difficulty adapting to novel situations, tolerating uncomfortable sensory stimuli, and sitting quietly. This familiarization protocol uses Evidence-Based Practices (EBPs) to increase research participants&#39; knowledge and understanding of the specific activities and steps of the research protocol. The tools in this familiarization protocol are a social narrative, a visual schedule, the Premack principle, role-playing, and modeling. The goal of this familiarization protocol is to increase understanding and agency and to potentially reduce anxiety for child participants, resulting in a greater likelihood of the successful completion of the research protocol for the collection of EEG/ERP data.

Electrophysiological research is an important tool for identifying biomarkers of developmental disorders, including Autism Spectrum Disorders (ASD), but data collection in these populations remains challenging. This work presents a familiarization protocol to accompany research that includes electroencephalography (EEG) to improve the likelihood of collecting EEG data from children with ASD.

This paper includes a detailed description of a familiarization protocol, which is used as an integral component of a larger research protocol to collect ...

Neuroscience

Observation and Inspection

Source: <a href="https://www.jove.com/author/Jaideep+S._Talwalkar">Jaideep S. Talwalkar</a>, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
Observation and inspection is fundamental to physical examination and begins at the first point of contact with a patient. While observation and inspection are often used interchangeably, observation is a general term that refers to the careful use of one&#39;s senses to gain information. Inspection is an act limited to what one can observe visually, and when referring to physical examination, typically refers to findings on the surface of the body, rather than to behaviors. Skilled clinicians utilize all of their senses to assist with gaining an understanding of their patients, relying on vision, touch (percussion and palpation), and hearing (percussion and auscultation) primarily. Smell can also provide important diagnostic information during the patient encounter (e.g., personal hygiene, substance use, or metabolic diseases). Fortunately the sense of taste is largely a historical relic in medicine, though it is interesting to note that diabetes mellitus was diagnosed for many centuries by the sweet taste of the urine. Through experience, clinicians develop an important sixth sense - the gut instinct - that can only be gained through deliberate practice of clinical skills on thousands of patients over many years. The clinician&#39;s gut instinct, which is based largely on bedside observations, has been shown to be a strong predictor of serious illness. This video and the others in the clinical skills video collection are steps on the way to learning this level of mastery.

Inspection of the Skin, Eyes, Ears, Scalp and Medical History

Source: Jaideep S. Talwalkar, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
Observation and inspection is fundamental to ...

JoVE Science Education

Clinical Skills

Physical Examinations I

Accessibility to Clinical Care for People who use Wheelchairs

Source: Yetsa Tuakli-Wosornu1,2, Jaideep Talwalkar1; 1Yale School of Medicine, 2University of Pittsburgh
In the United States, 25% of the general population suffers from one or another type of disability. Ambulatory disabilities, or mobility impairments, represent the most common subcategory, comprising 14% of the country&#39;s populace. Different mobility-assistive devices, ranging from canes to scooters, enable increased independence and improved quality of life for those suffering from mobility impairment. Wheelchairs or wheeled mobility devices are the most important among these, and an estimated 2.7 million people in the US use manual and powered wheelchairs annually. In the future, these numbers will increase due to rising chronic health conditions and an aging population. People who use wheelchairs often experience barriers to medical services in healthcare settings due to generalized disability stigma, inaccessible medical settings, inadequately trained clinic staff, and the inability of healthcare providers to understand all of their patients&#39; needs.
Section 504 of the 1973 Rehabilitation Act and the 1990 Americans with Disabilities Act (ADA) are federal civil rights legislations that protect US citizens with disabilities from discrimination, and mandate appropriate accommodation(s) be provided to ensure equal access, opportunities, and care in all sectors of society, including healthcare. Those with mobility impairment who use wheelchairs are therefore protected under law, and must be afforded equal access to clinical care for the prevention and treatment of illness, injury, and disease. Despite the laws, many clinical settings still struggle to provide such an inclusive environment. The US Department of Justice and Department of Health and Human Services&#39; Access to Medical Care for Individuals with Mobility Disabilities summarizes practical strategies that healthcare settings should adopt to create an accessible, ADA-compliant clinical environment. Reviewing and implementing these and other strategies are essential if clinical practices are to offer people who use wheelchairs the same level of care as those who do not.
Most details related to the medical care for people who use wheelchairs are no different than for people without a disability. Such elements of the physical examination will not be reviewed in this video in order to emphasize points where care is often lacking or must be approached differently. Given the prevalence of mobility impairment, the protocol described below should be a standard practice in medical settings, rather than an exception in specially designed office spaces.

Source: Yetsa Tuakli-Wosornu1,2, Jaideep Talwalkar1; 1Yale School of Medicine, 2University of Pittsburgh
In the United States, 25% of the general ...

Physical Examinations IV

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient&#39;s care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient&#39;s health status.
Documentation maps the patient&#39;s health journey by creating a comprehensive and precise medical and legal record. It encompasses patient assessments, medical history, previous illnesses, procedures, medications, diagnostic tests, nursing interventions, healthcare provider notes, and other crucial details about patient care. It effectively captures and preserves the essence of this significant information by ensuring optimal word choice, structure, readability, and eloquence.
Reporting conveys information about a patient&#39;s health status, including their condition, needs, treatment plan, outcomes, and responses. This information can be communicated in written or verbal form and is essential for ensuring that healthcare providers fully understand the patient&#39;s health status.
Reporting can occur between a healthcare professional and a patient or a family member, between healthcare professionals, or between different departments within a healthcare facility. Accurate and timely reporting is critical to providing high-quality care and improving patient outcomes.
All members of the healthcare team contribute to the patient&#39;s health record. This collaborative effort is essential for maintaining continuity of care, ensuring each healthcare provider is informed about the patient&#39;s history, ongoing treatment, and intervention responses. Furthermore, it serves as evidence of the care provided, communicates essential information to other healthcare providers, helps protect healthcare providers from legal claims, and provides evidence in case of litigation.
From admission to discharge, nurses must accurately record the patient&#39;s status and responses to interventions. Comprehensive nursing documentation serves as a vital record of the patient&#39;s care journey, tracking progress and identifying any emerging trends or patterns, which can be accomplished by using this tool and communicating with other healthcare providers.
Accurate documentation aids healthcare professionals in making informed patient care decisions, providing a basis for treatment plans and interventions. Furthermore, adherence to documentation standards helps reduce the risk of errors and ensures care is delivered according to established protocols.
The medical record holds legal significance as it can be used as evidence in legal proceedings for both the plaintiff and the defense. Documentation within the medical record supports and serves as a record of the care provided while promoting transparency and accountability.
In essence, documentation and reporting are both administrative tasks and essential tools underpinning quality healthcare delivery. By providing a complete and accurate account of a patient&#39;s health journey, these processes contribute to effective collaboration, informed decision-making, and the overall well-being of individuals under medical care.

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential ...

Documentation and Reporting

KEY TERMS AND CONCEPTS

Ethical Issues

Nurses are essential in patient care, upholding the ethical principles of their profession and effectively navigating ethical dilemmas. Neglecting ethical issues can lead to inadequate patient care, compromised therapeutic relationships, and moral distress among healthcare workers.
Ethical Concerns in Healthcare:
<ul>
	<li>&#8226; Paternalism: Nurses often encounter situations where they must act without patient consent to safeguard their well-being or prevent harm. A common example occurs in cases of elder care, especially with patients who have advanced dementia. In such scenarios, a nurse might need to make immediate decisions about the patient&#39;s daily activities, such as eating or bathing, without obtaining explicit consent due to the patient&#39;s impaired cognitive abilities. Although taken to ensure the patient&#39;s health and safety, might override their autonomy, highlighting the ongoing ethical challenge of determining the best course of action in the face of diminished capacity.</li>
	<li>&#8226;&#160;Privacy and Confidentiality: Confidentiality and privacy are fundamental to medical ethics. Violations can undermine trust and lead to legal repercussions. For instance, discussing a patient&#39;s condition in a public space where unauthorized individuals can overhear details violates these confidentiality agreements. Similarly, the accidental disclosure of patient information through misdirected emails or faxes underscores the need for strict protocols in handling patient information electronically.</li>
	<li>&#8226;&#160;Understaffing and Resource Allocation: The shortage of nursing staff and resources often forces nurses to prioritize care, leading to moral and ethical dilemmas about who receives immediate attention and who must wait.</li>
	<li>&#8226;&#160;Informed Consent: Informed consent becomes challenging during medical emergencies or when patients need help understanding treatment plans. For example, an ethical dilemma arises when a patient with limited understanding refuses a life-saving procedure. Nurses must navigate between respecting the patient&#39;s autonomy and ensuring their well-being.</li>
	<li>&#8226;&#160;Shared Decision-Making: Shared decision-making promotes patient autonomy by involving them in care decisions. Ethical issues arise when there is a lack of transparency or when a patient&#39;s circumstances are overlooked. An example is when a patient&#39;s preference for alternative treatments is disregarded due to a healthcare provider&#39;s bias.</li>
	<li>&#8226;&#160;End-of-Life Care: Providing care to patients with severe illnesses or at the end of life often presents ethical challenges. For instance, conflicts arise when family members disagree with a Do Not Resuscitate (DNR) order, which involves withholding life-sustaining treatment upon cardiac or respiratory arrest. Nurses must balance respecting the patient&#39;s wishes with addressing family concerns.</li>
</ul>
Nurses can improve patient care and therapeutic relationships by recognizing and navigating these ethical dimensions. Integrating ethical principles into daily routines helps preserve patients&#39; dignity, rights, and welfare while fostering trust and respect within the healthcare environment. Continuous education and moral deliberation are essential for nurses to refine their decision-making skills and provide competent and compassionate care.

Nurses are essential in patient care, upholding the ethical principles of their profession and effectively navigating ethical dilemmas. Neglecting ethical ...

Ethical Dilemmas II

Resolving an ethical dilemma in healthcare involves a systematic approach that considers every aspect of the issue, respecting both the patient&#39;s needs and values and the healthcare professional&#39;s ethical obligations. Here are potential steps to resolve an ethical dilemma:
<ol>
	<li>Identify the ethical problem and dilemma: Begin by recognizing the presence of an ethical issue. An ethical dilemma arises when conflicting moral principles or values necessitate choosing between two or more equally undesirable alternatives. For instance, a patient with a terminal illness may wish to refuse life-sustaining treatment, conflicting with the healthcare team&#39;s duty to preserve life. Similarly, an unconscious patient who has verbally expressed to their loved one, acting as their medical power of attorney (MPOA), a desire not to receive life-sustaining measures presents a critical ethical dilemma when no DNR order is in place.</li>
	<li>Gather relevant information: Collect detailed information pertinent to the ethical dilemma, including the patient&#39;s health status, family background, religious beliefs, cultural factors, and insights from healthcare literature. It is also important to include any verbal commitments made by the patient about their care preferences as communicated through their MPOA, as well as the implications of these preferences for medical decisions.</li>
	<li>Determine the ethical elements of the problem: This step clarifies the facts, values, opinions, and principles involved. It requires a thorough examination of one&#39;s own biases and the acknowledgment of others&#39; viewpoints. Key ethical values to consider include autonomy (the patient&#39;s right to make decisions about their own life), beneficence (the obligation to do good), and non-maleficence (the duty not to harm).</li>
	<li>Verbalize the problem: Articulate the ethical dilemma concisely, encapsulating the issue&#39;s essence. For example, an appropriate way to verbalize the above issue might be &#34;Should the healthcare team respect the unconscious patient&#39;s previously expressed wish to refuse treatment, thereby honoring their autonomy, or intervene to preserve life, adhering to the principle of beneficence?&#34;</li>
	<li>Determine possible courses of action: Identify all viable options for action, considering the resources available for guidance and support. These could include consulting with ethics committees&#39; legal advisors, or drawing upon the expertise of interprofessional team members. In cases like that of an unconscious patient without a DNR but with a verbal commitment to a loved one, it might be crucial to refer the matter to the ethics committee for navigating the complexities of patient autonomy versus clinical obligations.</li>
	<li>Create and execute an action plan: Develop a plan of action, considering several alternatives to address the dilemma effectively. The plan could include further discussions with the patient&#39;s family, seeking a second opinion, or arranging a meeting with an ethics committee to explore all possible options thoroughly and ensure that the patient&#39;s wishes are ultimately honored.</li>
	<li>Evaluate the plan over time: Continuously assess the effectiveness of the implemented strategy. The healthcare professional must be prepared to adjust the course of action based on the outcomes and any new information that emerges. If the initial plan does not lead to a satisfactory resolution, further actions should be considered, ensuring the ethical dilemma is addressed comprehensively.</li>
</ol>
Through this structured approach, healthcare professionals can navigate ethical dilemmas with a clear framework, ensuring decisions are made thoughtfully, respecting all individuals involved, and adhering to ethical principles, with a focused commitment to honoring patients&#39; wishes as expressed or communicated through their designated proxies.

Resolving an ethical dilemma in healthcare involves a systematic approach that considers every aspect of the issue, respecting both the patient&#39;s ...

Role of Communication in the Nursing Process III: Evaluation and Documentation

A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
<ul>
	<li>&#8226;&#160;Improved patient&#39;s condition</li>
	<li>&#8226;&#160;Stabilization of the patient&#39;s condition</li>
	<li>&#8226;&#160;Worsening of the patient&#39;s health.</li>
</ul>
Nursing evaluation entails gathering data, comparing it to desired outcomes, analyzing patient responses to nursing activities, and identifying factors contributing to the care plan&#39;s success or failure.
Nurses and healthcare team members are legally required to document patient care. Documentation should be objective, factual, and professional and use proper medical terminology, grammar, and spelling. All documentation must include the date, time, and signature of the person documenting. Abbreviations should be avoided. Any documentation in a health record is considered a legal document and must be completed in an accurate and timely manner. A real-time, patient-centered electronic health record (EHR) makes information available to authorized users promptly and securely.
Nursing documentation records the nursing care planned for and given to specific patients by licensed nurses or other caregivers acting under a licensed nurse&#39;s guidance. Nursing documentation is the primary clinical information source to satisfy legal and professional standards. Whether it is carried out manually or electronically, it is essential to safe, moral, and efficient nursing practice.
The Purpose of Documentation
Documentation is used for many purposes. It is used to ensure continuity of care across healthcare team members and shifts, monitor standards of care for quality assurance activities, and provide information for reimbursement purposes by insurance companies, Medicare, and Medicaid. Documentation may also be used for research purposes or, in some instances, legal concerns in a court of law.
Disclaimer: This text is adapted from <a href="https://wtcs.pressbooks.pub/nursingfundamentals/chapter/2-4-communicating-with-health-care-team-members/">Nursing Fundamentals, Open RN, Section 2.5.Documentation, </a>

A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done ...

Communication

Methods of Documentation IV: Focus Charting

Focus Charting, also known as the focus charting system or &#34;focus documentation,&#34; is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
<ol>
	<li>The date and charting column records the date and time of each entry, providing a chronological record of patient activities.</li>
	<li>Focus: The focus column includes information about specific patient concerns or issues, such as nursing diagnoses, signs or symptoms, patient behaviors, special needs, acute changes in condition, or significant events. Each entry in this column highlights a particular focus on the patient&#39;s care.</li>
	<li>Progress Notes (DAR Format):</li>
</ol>
<ul>
	<li>&#8226; The data category is like nursing assessment. This section documents subjective and objective data related to the corresponding focus. It may include vital signs, patient behavioral observations, laboratory results, or other relevant information.</li>
	<li>&#8226;&#160;The action category is the implementation phase of the nursing process, which encompasses planning, execution, and incorporating immediate and future nursing actions. This phase documents the actions taken in response to the corresponding focus, customized to the patient&#39;s condition and rooted in nursing assessments and evaluations. Furthermore, the care plan may be adjusted based on these assessments to ensure optimal patient care.</li>
	<li>&#8226;&#160;The response category represents the evaluation phase of the nursing process and encompasses the patient&#39;s response to nursing and medical care. This section details the patient&#39;s reaction to the care received, encompassing changes in their condition, improvements or worsening of symptoms, and any pertinent observations that indicate the effectiveness of the provided care.</li>
</ul>
The DAR format in progress notes organizes patient care activities and outcomes, streamlining documentation.
Advantages:
Focus Charting offers vital advantages. It saves nurses&#39; time, reduces duplicate charting, improves data readability and organization, facilitates communication among care team members, encourages regular documentation of patient responses, and is adaptable to various clinical settings and documentation systems, including computer-based ones. It promotes efficiency, clarity, and precision in nursing documentation while focusing on the nursing process and individual patient needs.
Disadvantages:
The disadvantage of focus charting is that some nurses may need help to organize information in the DAR format due to time constraints. This format requires careful consideration and documentation of data, actions, and responses, which can be challenging to accomplish in busy clinical settings.

Focus Charting, also known as the focus charting system or &#34;focus documentation,&#34; is a systematic documentation approach used in healthcare to ...

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient&#39;s condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness like diabetes may benefit from input from a primary care physician for medical management, a dietitian for dietary guidance, and a nurse for care management.
In the realm of case management, the use of a critical pathway is a fundamental element. This structured and evidence-based care plan, also called a clinical care pathway or care pathway, is a guide for healthcare providers, outlining the sequence of interventions and expected outcomes for a specific patient population or medical condition.
Critical pathways aim to achieve optimal outcomes within a defined timeframe by incorporating key milestones, timelines, and targeted interventions. They act as navigational tools, promoting standardized care delivery, reducing practice variations, and optimizing resource utilization. Critical pathways empower healthcare professionals to provide efficient and effective care, which is particularly valuable for conditions with well-established treatment protocols, such as elective surgeries, pneumonia, or heart failure.
Next, variance charting, or charting by exception, is a documentation method that tracks and analyzes deviations from the planned critical pathway. When a patient&#39;s progress deviates from what was anticipated, or expected outcomes are not met, healthcare providers document the variances, including the cause, actions taken in response, and any necessary adjustments to the care plan. By systematically documenting variances, healthcare teams can identify trends, root causes, and opportunities for improvement in care delivery.
For instance, if a patient experiences a delay in recovery following surgery, variance charting helps pinpoint factors contributing to the delay, such as postoperative complications or inadequate pain management. These enable prompt intervention and resolution.
The case management model brings numerous benefits to patients and healthcare providers.
<ul>
	<li>&#8226; Collaboration and standardized care protocols enhance communication and coordination across different healthcare settings.</li>
	<li>&#8226;&#160;It improves patient outcomes, reduces readmissions, and enhances satisfaction.</li>
	<li>&#8226;&#160;The structured approach of critical pathways and variance charting improves quality and fosters data-driven decision-making.</li>
	<li>&#8226;&#160;Emphasizing teamwork creates a culture of respect, responsibility, and professional development among providers.</li>
</ul>
Despite its advantages, the case management model may have limitations in specific scenarios.
<ul>
	<li>&#8226;&#160;Patients with chronic medical conditions, multiple comorbidities, or unique psychosocial needs may require more individualized and flexible care approaches beyond standardized protocols.</li>
	<li>&#8226;&#160;Managing such patients within predetermined pathways is challenging and requires significant clinical judgment, creativity, and adaptability from healthcare providers.</li>
	<li>&#8226;&#160;Additionally, the resource-intensive nature of case management, including interdisciplinary collaboration, documentation, and ongoing monitoring, can pose logistical and financial challenges for healthcare organizations, especially in resource-constrained settings.</li>
</ul>

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, ...

Formats for Nursing Documentation

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let&#39;s explore each of these formats in detail:
Nursing Assessment Form:
&#8226;&#160;A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
&#8226;&#160;It includes patient demographics, medical history, current medications, vital signs, physical examination findings, and pertinent nursing observations.
Kardex:
&#8226;&#160;The Kardex is a nursing record filing system that concisely summarizes patient information for quick reference.
&#8226;&#160;Historically, Kardex cards were stored in a central file, but modern systems have transitioned to electronic formats.
&#8226;&#160;The exterior of the Kardex card typically displays key patient details, including diagnosis, activity levels, diet, vital signs, diagnostic investigations, medications, and treatments.
&#8226;&#160;The interior contains a nursing care plan outlining nursing diagnoses, desired outcomes, interventions, and safety precautions.
Nursing Care Plan:
&#8226;&#160;A nursing care plan is a roadmap for nurses and patients to collaborate in achieving healthcare goals.
&#8226;&#160;It usually follows a structured format that includes sections on nursing assessment, diagnosis, plan, intervention, and desired outcome.
&#8226;&#160;The nursing care plan guides nursing interventions and facilitates ongoing assessment and evaluation of patient progress.
Critical Pathways:
&#8226;&#160;Critical pathways are interdisciplinary care plans that outline patient problems, necessary interventions, and expected outcomes within specific timeframes.
&#8226;&#160;They provide a standardized framework for coordinating care across different healthcare disciplines and settings, promoting consistency and efficiency in patient management.
Progress Notes:
&#8226;&#160;Progress notes document a patient&#39;s progress toward expected outcomes and inform caregivers about changes in the patient&#39;s condition.
&#8226;&#160;Focus charting is an example of a progress note format that emphasizes patient concerns, actions taken, and patient responses to interventions.
Flow Sheets:
&#8226; Flow sheets document patient conditions and trends, such as vital signs, intake and output, pain assessments, and other parameters.
&#8226;&#160;They provide a visual representation of patient data, allowing healthcare providers to track changes in patient status and identify patterns or trends that may require intervention.
By utilizing these various documentation formats, nurses can ensure accurate, comprehensive, and easily understandable patient records, facilitating effective communication and coordination of care among healthcare team members.

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ...