CLINICAL PLACEMENT ONBOARDING MANUAL

Family Nurse Practitioner Program University of Mary 7500 University Drive Bismarck, ND 58504

Dr. Billie Madler, DNP, APRN, FNP, FAANP Dr. Jenna Herman, DNP, APRN, FNP-C Chair, Graduate Nursing FNP Program Coordinator 701.355.8266 701.355.8116 [email protected] [email protected]

Jody Martin Dr. Annie Gerhardt, DNP, APRN, FNP-C Clinical Placement Liaison FNP Clinical Competence Coordinator Graduate Nursing 701.319.1101 701.355.8127 [email protected] [email protected]

1 Table of Contents Introduction/Purpose of Clinical Experiences ...... 3 Overview of Clinical Courses ...... 3 Types of Clinical Facilities...... 3 Preceptor Qualifications ...... 4 Clinical Placement Process ...... 4 Clinical Placement Overview ...... 4 Clinical Process Steps ...... 5 Preparing for Clinical Placement ...... 7 Common Additional Expectations of Clinical Facilities ...... 9 Clearance to Begin Clinical Experience ...... 9 Miscellaneous Clinical Concerns ...... 10 Student Liability Insurance...... 10 Clinical Travel Requirements ...... 10 Clinical Attendance ...... 10 Working during Clinical Courses ...... 11 On-call Hours...... 11 Surgical Hours ...... 11 Characteristics of the Clinically Engaged Student ...... 11 Other Student Clinical Responsibilities ...... 14 Professional Behavior ...... 16 Establishing Baseline Student Clinical Competence ...... 16 Overview of Student Clinical Evaluation Methods ...... 16 Clinical Placement Meetings ...... 17 NP Skills Checklist ...... 17 Student Clinical Objectives/Evaluation ...... 17 Clinical Conference Group Meetings ...... 17 Clinical Site Visit ...... 17 Typhon Entries ...... 18 Dictations ...... 18 Preceptor Typhon Evaluations ...... 18 Hotseat Competency Testing ...... 19 Appendices A. Graduate Nursing Student Health Requirements ...... 20 B. NP Skills Checklist …………………………………………………………………………………………………………….. 22 C. Clinical Placement Information Form ...... 26 D. Student Clinical Contract with Objectives/Evaluation Examples ...... 29 E. 3 Minute Clinical Presentation ...... 36 F. Typhon Guidelines/Examples ...... 42 G. Dictation Requirements ...... 46 H. Clinical Site Visit Tool ...... 56 I. Selecting the Appropriate E/M Coding ...... 62 J. Hotseat Pearls ...... 64 K. Preceptor Thank You Letter with Preceptor Benefits ...... 76

2 Introduction Clinical rotations are an important component of the academic experience in the BSN to DNP program and are critical to the formation of competent Family Nurse Practitioner (FNP) graduates. This manual intends to serve as a roadmap for common questions surrounding clinical requirements, placements, and expectations.

Purpose of Clinical Experiences Planned clinical experiences, guided by qualified and competent preceptors are essential for student growth and development in clinical and professional skills necessary for preparedness to function as a competent nurse practitioner upon graduation. Under careful supervision of clinical preceptors, students apply classroom principles to real life experiences in healthcare settings.

The clinical experience sets the stage for students to begin their professional networking. It is a time when students are marketing themselves and the University of Mary. They are on stage and not only are they being assessed by preceptors but also by nurses, clinic staff on their performance with histories, physicals, diagnosis and management. Students are being assessed on their professionalism, communication style, personality, interpersonal relationship skills, teamwork mentality, etc. And equally important, students are representing the University of Mary FNP program and their interactions are a direct reflection of our program. How students market themselves can affect the program either positively or negatively for generations to come. Overview of Clinical Courses FNP students will complete a minimum of 1180 clinical hours during their course of study. Of these, a minimum of 900 will be in direct patient care. This manual discusses important information related to the direct patient care clinical experiences required of FNP students.

In the final clinical course NUR 960, the required number of clinical hours is 400. Student must engage care of the primary care population for a minimum of 150 hours during this course and may not have more than 3 unique clinical placements.

The first year of the program provides challenging coursework foundational to the preparation of students for direct patient care experiences. Direct patient care experiences will commence fall semester of year 2 in the FNP program of study. Table 1 outlines the direct patient care clinical courses and their position in the program of study.

Table 1 FNP Direct Patient Care Clinical Courses Course Number Course Name Number of Required Hours Semester/Year NUR 759 Primary Care Clinical 200 Fall of Year 2 NUR 859 Women and Children Clinical 150 Summer of Year 2 or Fall of Year 3 NUR 869 Special Populations Clinical 150 Summer of Year 2 or Fall of Year 3 NUR 960 Seminar and Practicum 400 Spring of Year 3

Types of Clinical Facilities Direct patient care experiences occur in a wide range of clinical settings. The type of setting will be dependent on the clinical course and faculty’s suggestions based on previous clinical experience exposure and performance. The care delivered at the setting must match the objectives of the course. Table 2 offers examples of clinical settings based on clinical course.

Table 2

3 Examples of Clinical Settings by Course Course Number Course Name Example of Clinic Setting NUR 759 Primary Care Clinical Primary Care/Family Practice Clinic, Federally Qualified Health Center, Long Term Care Facility NUR 859 Women and Children Clinical OB/GYN Clinic, Pediatric Clinic, Family Practice Clinic NUR 869 Special Populations Clinical Orthopedics, Cardiology, Pulmonology, Pain Management, Dermatology, Rheumatology, Neurology, Oncology, Nephrology, Urgent Care, Hospitalist, Emergency, etc NUR 960 Seminar and Practicum Primary Care/Family Practice Clinic, Federally Qualified Health Center, Mental Health, Diabetes Management, Long Term Care Facility OB/GYN Clinic, Pediatric Clinic, Family Practice Clinic Orthopedics, Cardiology, Pulmonology, Pain Management, Dermatology, Rheumatology, Neurology, Oncology, Nephrology, Urgent Care, Hospitalist, Emergency, etc

Preceptor Qualifications To assure students can fulfill clinical obligations of each course, it is important for the University of Mary FNP faculty to carefully screen and, to the best of their ability, select preceptors who are motivated to teach, are willing to devote time to student’s learning, and are ready to allow students hands on experiences in practice and clinical documentation. A minimum of 200 hours with a nurse practitioner, over the course of the program of study, is a University of Mary program requirement.

Preceptor qualifications are verified by several means including a review of the preceptor credentials, curriculum vitas, and from previous evaluations of that preceptor. Other means include web inquiries for biographies commonly found on clinical agency pages and contacts to medical staff service or credentialing offices for verification of preceptor qualifications.

Basic preceptor qualifications required include the following: • Nurse Practitioner, Certified Nurse Midwife, Physician (MD), Osteopathic Physician (DO), Physician Assistant (PA). • Current licensure in state of proposed clinical preceptorship (except providers practicing in US government settings). • Preceptor’s practice is in an area related to content of clinical course. • A minimum of one year of work experience. Clinical Placement Process The clinical placement process is a collaborative effort between FNP Faculty, Graduate Nursing Clinical Placement Liaison, the student, the healthcare organization, and the preceptor. In accordance with the Commission on Collegiate Nursing Education, the program maintains overall responsibility for determining and securing placement of students in clinical experiences. Designated FNP faculty are responsible for approving a potential preceptor and clinical setting prior to the pursuit of a clinical placement. Faculty consider the credentials of potential preceptors, the appropriateness of the clinical site regarding the clinical course, and the population served in relationship to the intended objectives of the experience. Upon approval from faculty, the Graduate Clinical Placement Liaison makes an initial communication to request a clinical rotation with the preceptor, communicates if the placement was

4 secured or not, and executes necessary paperwork for secured placements between students, faculty, clinical organization, and preceptor. What you can expect Faculty work to place students with preceptors who work in settings near the student’s home, however, that is not always possible or appropriate to the objectives of the placement. See Clinical Travel Requirements section for additional information.

In many cases, the clinical placement process can take months to accomplish. Therefore, it is important to plan and begin placement work early. Ongoing, timely communication between FNP Faculty, Graduate Nursing Clinical Placement Liaison, and the student is important to facilitate the process.

Life happens. Sometimes secured placements fall through at the last minute. Sometimes finalized placements do not occur in a timely manner (this may be due to a variety of causes including preceptors or clinical sites are not responsive, delay in signed agreements, legal review of affiliation agreements are not approved, additional backgrounds studies are needed and cause delays, etc.). As professionals, faculty, students, and staff must be prepared to adapt and rise to the occasion.

Faculty, staff will use Monday.com, a cloud-based project management application, to organize the work associated with each student’s placement and to facilitate communication between and among faculty, staff, and students.

Steps in the Clinical Placement Process Coordinating a clinical placement can be challenging, however the rewards of a quality clinical experience are invaluable to the future success of graduates. A well-defined clinical placement process is in the Graduate Nursing Student Handbook. Listed below are the key activities associated with the clinical placement process. Please note: 1. Students are not allowed to inquire with prospective preceptors until granted permission by the Graduate Nursing Clinical Placement Liaison. 2. Care is taken to place the students with a preceptor and a location that will best equip them to achieve required clinical competencies associated with that course. While a goal is to place the student in a location in or near their home community, or somewhere the student has friends or family, occasions do arise that the student will be required to travel for their clinical experience. All students can expect that they will be required to travel for clinical experiences during their program of study. 3. State regulations may prevent the University of Mary from placing students in some states. In circumstances the student is contemplating moving to a different state, it is advisable for that student to communicate early with the FNP Program Coordinator.

Clinical Placement Process: 1. During December of Year 1, the student will receive an invite to Monday.com, CastleBranch Registration, and instructions for completing renewal Background Check Requirements. 2. Student completes and submits an online Clinical Placement Information Form (Appendix C) and NP Skills Checklist (Appendix B) to Monday.com. 5 3. Student completes CastleBranch and Background Check Requirements and continues updates through out the ENTIRE FNP Program. 4. Student schedules a Clinical Placement Planning Meeting January of First Year. A sign up will be sent to students University of Mary email by the FNP Clinical Competency Coordinator. 5. Student meets with FNP Clinical Faculty and Graduate Nursing Clinical Placement Liaison to review Clinical Placement Information Form, NP Skills Checklist to discuss and plans are made for clinical practice sites/preceptors during the Clinical Placement Planning Meeting. 6. Faculty approves proposed clinical placement plan, preceptor, and setting. 7. Graduate Nursing Clinical Placement Liaison: a. Verifies if student requirements are in place (i.e., immunizations, required certifications, criminal background check). If not in place, no further work on placement continues. b. Makes contacts to student placement coordinators at potential preceptors’ affiliated practice settings. c. Documents notes related to dates/types of communications, response to communications, etc. d. Determines if interagency contracts are in place for potential setting. If interagency agreements are not in place, sends University of Mary Memorandum of Understanding for signatures or forwards clinical site’s affiliation agreement to University of Mary’s Legal Counsel for review and approval. Once draft is approved, sends on to collect signatures. e. Communicates accepted or declined placements to faculty and student. f. Moves to alternative placement options when necessary (i.e. declined placement, untimely communication from potential preceptor or organization, etc.). g. Inquires about site-specific paperwork (HIPAA, confidentiality forms, verification of background checks and immunization requirements). Sends paperwork to student, collects and submits to clinical site. (Some sites use online attestation, and others require UMary to “sign off” on forms or rosters (Excel spreadsheets) and submits back to clinical site. h. Inquires about computer access, badging, parking, etc. as needed and/or passes on information to the student. i. Asks for scheduling instructions and contact information, as needed. j. Adds clinical site and preceptor into Typhon. 8. Once a preceptor has accepted a student, two documents must be in place: a. Affiliation Agreement/Memorandum of Understanding (MOU) (agreement between the University of Mary and the organization where the clinical experience will occur). b. Letter of Agreement (an agreement between the preceptor and the FNP program). The letter of agreement contains the following information: • Student name • Student responsibilities • University name • Course number • Clinical site/organization name and address • Timeframe, number of hours requesting, and specialty area • Preceptor’s name and address • Preceptor responsibilities • Clinical faculty name and contact information • Clinical faculty responsibilities • FNP Clinical Competence Coordinator name and contact information

6 • FNP Clinical Competence Coordinator responsibilities 5. Graduate Nursing Clinical Placement Liaison creates and sends the letter of agreement to the approved preceptor. The letter of agreement must be signed and returned by the preceptor, FNP Competence Coordinator, clinical faculty, and FNP student before initiating the clinical experience. 6. In addition to the letter of agreement, the Graduate Nursing Clinical Placement Liaison sends a copy of the University sponsored liability insurance coverage on students is sent to the facility. 7. Graduate Nursing Clinical Placement Liaison gathers any additional required pre-courses, scheduling information, contact information, etc. and provides a Clinical Approval Letter to the student upon verified completion and signing of the Memorandum of Agreement and Clinical Letter of Agreement. This step may take 2 - 3 weeks. The student cannot begin scheduling or start clinicals until this letter has been received and any additional facility requested requirements (such as EPIC training) are completed by the student. 8. Graduate Nursing Clinical Placement Liaison, in collaboration with students, ensures the preceptor and clinical site information is up to date in the clinical tracking system (Typhon®). 9. Student establishes their clinical schedule in collaboration with their preceptor within two weeks of receiving clinical placement confirmation. Clinical faculty will establish the timeframe within each semester for clinical placement completion to ensure necessary course material has been covered prior to the rotation. This timeframe, along with the means by which the preceptor would like to be contacted for scheduling, will be communicated to the student via the Graduate Nursing Clinical Placement Liaison. 10. Students enter their clinical schedule into the clinical tracking system (Typhon®), as well as log each patient encounter and track daily time logs. The FNP Clinical Competence Coordinator and assigned clinical faculty from each respective course will monitor both the online clinical schedule and Typhon® patient encounter entries. 11. FNP Clinical Competence Coordinator will communicate with preceptors at the beginning of the semester. This communication is meant to strengthen the connection between the preceptor and clinical faculty. The message will include the preceptor manual, reiterate student expectations and extend contact information for the preceptor to reach faculty. 12. Student facilitates the scheduling of a clinical site visit near the midpoint of the student’s experience with clinical faculty and the preceptor. The purpose of the site visit will be to evaluate the student’s experience, the student’s performance and clinical site effectiveness. This clinical site visit may occur by one of several mechanisms (i.e., in person, over the phone, or technologically facilitated). It is the student’s responsibility to schedule the site visit. 13. Student notifies the FNP Clinical Competence Coordinator once they have completed all clinical experiences. 14. FNP Clinical Competence Coordinator will send the preceptor a student evaluation. Students must also complete an evaluation of the clinical site. Students are strongly encouraged to save a copy of the evaluation in their e-Portfolio. 15. FNP Clinical Competence Coordinator will send the preceptor a thank you note and a letter documenting the hours of service provided on behalf of the FNP Program, student, and faculty. 16. Student sends a thank you card to their preceptors for their time and commitment.

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Preparation for Clinical Placement In order to begin the clinical placement process, students are required to submit several documents noting they are a healthy and safe student that meets the requirements of the assigned clinical sites. The student will be asked to submit documents or certificates of course completion to a variety of databases including CastleBranch (https://www.castlebranch.com/sign-in), Typhon (https://www3.typhongroup.net/np/data/login.asp?facility=), and/or other facility databases such as MyClinicalExchange, or site specific healthcare websites for onboarding students.

It is imperative to be responsive to any requests for additional documentation within a TIMELY manner. If students fail to keep their requirements or submit documents timely, the University of Mary will not be able to proceed with clinical placement. At minimum clinical placement takes two months, though for many clinical sites, especially any military, Indian Health Service, or Government Facility, it may take six to twelve months to complete the clinical placement process. It is essential for the student to read, understand, and follow any requests from your Graduate Nursing Clinical Placement Liaison, FNP Clinical Competence Coordinator, or the specific clinical placement facilities so contracts and plans can be made well in advance to solidify an experience that will be of benefit to the student as they progress through the program.

For the Graduate Nursing Clinical Liaison to begin work on student placements, it is necessary for all immunizations and the criminal background checks to be up to date and to remain up to date throughout the entirety of the clinical experience.

Graduate Nursing Student Requirements Student must hold a current, unencumbered nursing license throughout their academic program. Students may be required to have a current nursing license not only in the state they work in but also in the state/s in which they participate in clinical or practical experiences. ONE TIME SUBMISSION SUBMITTED ANNUALLY Immunizations: IMMUNIZATIONS: HEPATITIS B INFLUENZA • Series of 3 vaccines completed at appropriate • Proof of seasonal vaccination time intervals. MMR (Measles, Mumps, Rubella) • Proof of immunity by titer for Measles, Rubella, and Mumps OR • Proof of vaccination (2 doses at appropriate intervals) Immunization requirements are defined in the VARICELLA (Chicken Pox) Graduate Nursing Students Health Requirements • Proof of immunity by titer OR Policy. Please refer to Appendix A for a copy of this • Proof of vaccination (2 doses at appropriate policy. intervals) TETANUS, DIPTHERIA, PERTUSSIS (Tdap) • Tdap required once • Td required every 10 years after Tdap Tuberculin Status: TUBERCULIN STATUS: • Documentation of an initial 2 step TST is required • Annual TST OR AND documentation of annual TST’s since 2 step • Annual TB IGRA test (TSpot or Quantiferon) completed. • If newly positive TST/IGRA results >F/U with o If no previous record or more than 12 healthcare provider (chest x-ray, symptoms check months since last TST>2 step TST OR and possible treatment documentation of

8 o Negative TB IGRA test (Tspot or absence of active M. TB disease) and may need to Quantiferon) within 12 months OR complete health questionnaire. o If negative TST within 12 months > one • Previously documented + TST results and prior step TST negative chest x-ray results: submit annual • If newly positive TST or TB IGRA > F/U by health symptom check completed within one year from care provider (chest x-ray, symptoms check and healthcare provider. possible treatment documentation of absence of active M. TB disease) and need to complete health questionnaire • If history of positive TST>provide documentation of TST reading, provide proof of chest x-ray documenting absence of M.TB, medical treatment BACKGROUND CHECK and negative symptoms check OR Annual background re-check. o If history of BCG vaccine >TST Skin Testing as above or TB IGRA (TSpot or Quantiferon). If negative >OK; if positive > follow-up as above. TRAININGS/CERTIFICATIONS: ADDITIONAL SITE SPECIFIC Students are responsible to locate, register and fund REQUIREMENTS THAT MAY APPLY all required certification courses. The student is also On request from an affiliated organization for which responsible to upload a copy into their Medical the student is engaged in a learning experience, the Document Manager on CastleBranch. Graduate Nursing Program will share student • American Heart Association (AHA) BLS Healthcare immunization information. At times, affiliated Provider Card organizations may have additional health • Prior to NUR836 requirements. In these situations, the student will be o Pediatric Advanced Life Support (PALS) held responsible for compliance with these o Advanced Cardiac Life Support (ACLS) requirements. Please see additional note below. o Trauma Nursing Core Certification (TNCC) BACKGROUND CHECK Additional requirements may include the following: A National Criminal background check upon admission • Drug screen (Please see “Policy on Drug Testing” to program and updated annually. Please refer to in Graduate Nursing Student Handbook your Graduate Nursing Student Handbook for more • Personal Health Insurance specific information/requirements. • Vehicle Insurance (for access to VA and Military SIGNED RELEASE OF INFORMATION Clinical Sites) • Kept on file with program • Hepatitis A Vaccine COMPLETED MEDIA RELEASE • Proof of US Citizenship • Kept on file with program • Color Blind Test CV/RESUME/BIOSKETCH • HIPAA and/or OSHA Training • CV/Resume/BioSketch/Professional Headshot • Department of Human Services Background Study Picture will be uploaded upon admission. Student • EPIC or other computerized documentation will be responsible for updating CV/BioSketch training annually to include contact information.

Common Additional Expectations of Clinical Facilities Most clinical facilities employ staff in clinical education departments that assume the role of working with Universities to coordinate the placements of students. Many have their own algorithm for determining how individuals are prioritized for placements (employee or not, program, etc.). Nearly all restrict programs or students from asking preceptors directly regarding their willingness to be a preceptor. Agencies have their own timelines that they follow which sometimes does not line up well with the timeline needs of the program. This challenge can complicate the seamless placement of students. Immunizations, background checks, sometimes drug testing, completion of the facilities unique onboarding process (which requires separate paperwork and training usually on Electronic Health Records take time.

9 Unfortunately, these hours don’t count toward the clinical requirement – and students must accommodate the meetings times the clinical agency offers to them for this training. Clearance to Begin Clinical Experience 1. All clinical and FNP placements must be secured and approved by University of Mary Faculty. 2. Students are NOT to attempt to request, contact, or schedule their own clinical experiences unless given explicit direction to do so by the Graduate Nursing Clinical Placement Liaison or FNP Clinical Competence Coordinator. 3. Once the Graduate Nursing Clinical Placement Liaison has verified completion and signing of the Memorandum of Agreement and Clinical Letter of Agreement, the Graduate Nursing Clinical Placement Liaison will gather any additional required pre-courses, scheduling information, contact information, etc. and provide a Clinical Approval Letter to the student. This step may take 2 - 3 weeks. The student cannot begin scheduling or start clinicals until this letter has been received and any additional facility requested requirements (such as EPIC training) are completed by the student. Miscellaneous Clinical Concerns Student Liability Insurance A group policy of liability insurance is provided by the University of Mary. As a practice discipline, nursing deals with the public and may be subject to litigation. Therefore, liability insurance is mandatory for all nurse graduate students. A separate fee will appear on the student financial billing statement annually. Liability insurance provides coverage only during approved clinical rotations and time frames. This is not a health insurance policy. Students must maintain their own health insurance.

Clinical Travel Requirements The University of Mary will place students in clinical experiences that are expected to provide students with the best tools and experiences necessary to meet program objectives, support future clinical practice, and obtain the most independent opportunities to practice as a student. Depending on where a student is located, there may not be access to necessary preceptors who can assist with providing adequate clinical exposure to meet program requirements. Travel will be required. Some clinical sites do provide housing; however, it is not the standard. Students are responsible for their own transportation and lodging expenses incurred for any experiences related to their academic program of study. Students are not allowed to transport clients, due to liability concerns.

Clinical Attendance Clinical attendance is mandatory. Students are required to enter their clinical schedule into the Typhon Clinical Tracking Software. Students are required to be at their clinical site during their scheduled clinical hours. The Typhon Calendar will be used as needed to verify student compliance with clinical hours and planning clinical site visits. No missed hours of clinical will count towards a student’s total number of required hours. Students must complete the required number of clinical hours per semester to successfully progress in their program of study. If an extenuating circumstance creates an unforeseen absence such as illness, family emergency, or inclement weather, the student must contact both their preceptor and clinical faculty as soon as possible. It is the student’s responsibility to assess the safety of travel conditions if travel to clinical is required. Any time lost must be made up during the same semester. In extenuating circumstances, arrangements are to be made with course faculty and the FNP Program Coordinator to find an alternative clinical site.

10 Failure to Adhere to Attendance Requirements Consequences of a single unexcused absence for a scheduled synchronous class meeting may result in any of the following: * Dismissal from the course * 5% reduction in overall course grade * A zero for the related assignment Absence from scheduled clinical experiences and/or class without prior approval will be recorded as an unexcused absence. Two unexcused absences will place student on probation. Notification of this status will be given in writing. Further unexcused absences may result in termination from the program. Working during Clinical Courses Some students will ask to complete clinical placement where they work. Students may complete clinical hours where they work, however, students MAY NOT conduct hours within the same department where the student is normally in an administrative or leadership position and or other relationship that may results in a conflict of interest. For example, student is working part-time as a clinical manager in an urgent care clinic, then returns to complete clinicals under a provider and with clinical staff the student is responsible for “managing” during regular working hours. This situation results in a potential conflict of interest.

Most students will work a part-time or PRN status while in the FNP program. The first year is more feasible, however, once clinical courses start, most students find it very difficult to keep up with all the rigors and requirements of a doctoral nursing practice program. Placements will not be based on specific student scheduling needs. Work will not be an accepted excuse for missing clinical or mandatory student meetings/presentations/institute. If students choose to continue working, it is crucial that an employer be flexible with the student’s work schedule, as most offices operate on a Monday to Friday, 8 am to 5 pm schedule, which will conflict with scheduled clinical and class periods. Overall, the University of Mary Graduate Nursing Program highly recommends that students do not work, or work only a minimal number of hours, during clinical course semesters.

On-Call Hours A preceptor may be on call for a 24-hour period or longer, but the maximum number of hours a student may count towards their clinical in a 24-hour period is 16 hours. Furthermore, students may only log the hours they are actively engaged in patient care. On-call hours may not be logged.

Surgical Hours If the facility and preceptor are willing, students can follow and assist in surgery. Students may use a portion of the clinical hours spent in the Operating Room (OR) for credit during the clinical experience depending on the length of the clinical experience. Students will need to communicate with Clinical Faculty prior to entering the OR regarding how many hours may be applied for clinical credit. Students would still include these patient exposures in the Typhon Clinical Tracking System.

Characteristics of the Clinically Engaged Student Be open and willing to extract as much experience and knowledge from each one of your clinical preceptors and clinical sites. Always be asking the question, how can I apply this experience to my FNP objectives and future clinical practice? Each student depending on their location may have different and varied sites, but all students can expect their clinical experiences to meet program objectives.

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Here are some comments to contemplate as you embark on the clinical experience:

• Always keep in mind the two primary goals of clinical training: To learn to care for patients in an independent role and to help develop professional identity as a nurse practitioner. o It is easy to be distracted by worries about how well you are doing and what your teachers and preceptors think about your performance. However, maintaining a clear focus on these two goals above will help you maintain perspective during challenging times of your clinical experience. o Consider each placement as an “audition” for future placements. The reputation you develop while in your clinical rotations can open doors for future rotations, and even future employment. Alternatively, a negative experience with a student can impact a sites’ willingness to place future students. o Formally thank each preceptor and staff who assisted you at the end of each clinical rotation with at least a thank you note. • Be prepared for clinical rotations. o Prepare both academically and mentally for your rotations. From an educational perspective, look ahead to each rotation. Have the appropriate resources available before you start the rotation. Ask questions of previous students. o You will find that each preceptor has their own way of doing things and their own personality. Although this may feel a bit strange when you experience it (you will certainly find some rotations more comfortable than others) and take some getting used to, don’t be surprised, and try to take advantage of seeing how different preceptors view the world of clinical practice. • Work-life Balance o Work-life balance can be a major struggle. Consider cooking for the week on your day off and stock up on healthy snacks and easy to prepare foods. Recharge on your days off by doing something that gives you joy or peace of mind. For some it’s exercise, for others it could be watching television, brunch with friends, or writing in a journal. • Don’t underestimate your abilities. o The clinical experience is intended to help you apply the basic science knowledge you have acquired over the last semesters to real patients. This is an extremely difficult, frustrating, and often painful experience. At times you will feel as though you don’t know anything, and it is not uncommon for students to say that the more they experience, the more they realize how little they actually know. But don’t forget that you DO know a lot, and that over time things will become easier! Remember that those who are supervising and teaching you were at one point in the exact same position as you will be, and possibly not that long ago. Students also make major contributions to patient care and patient care teams, so always remember that your presence and engagement are valued. o During your rotation make your presence meaningful every day. If you are reliable and enthusiastic, you will be entrusted with a range of tasks, from minor to major. Most preceptors care less about your ability to ask every content question and more about your dedication to patient care and desire to improve your knowledge and skills during the rotation. o Keep track of to-do items for patients cared for during the day. If everything has been completed, volunteer to help with other patients by offering to run samples to the lab, call a

12 pharmacy to confirm a patient’s medication list, or find a clinically relevant article and summarize for the next day. Your effort to go above and beyond will be noted. • Don’t overestimate your abilities. o It is also important that you understand your own strengths and limitations to optimize your clinical learning. Many students feel as though they always need to have the correct answer or never need to ask for help in order to be successful. This approach can be a great hindrance when learning clinical practice. It is perfectly acceptable to indicate what you know and don’t know. You preceptors understand that you are early in training and that different students progress at different rates when transitioning from the classroom to the clinics. Do prepare to the best of your abilities. It’s ok to tell people what you need help with in order to fill in your knowledge and skill gaps. • Take advantage of this incredibly unique period in your professional training. o This will be the only time you will be able to become intensively involved with the different disciplines. So, despite the expected stress and anxiety that you will undoubtedly experience, when able find times to relax and enjoy the process. • Contact your preceptor within a week of gaining approval to schedule or reach out to your preceptor. o Ask about where to meet or how best to contact them on your first day so you know what to do when you arrive. Some work in areas that have employee-only access or are at a different location depending on the day of the week, so you need to have a plan for how you’ll connect before you get there. o Ask about particular resources you should bring. o Ask up front how your preceptor prefers to field questions. ▪ For many practices, asking questions as you go is routine. However, some practices are fast paced and more conducive to fielding groups of questions every few hours or at the end of the day. ▪ You want to ask as many questions as you can while on a rotation. Preceptors are gold mines for clinical pearls, career advice, and patient care strategies, and you don’t want to miss out on their insight. ▪ However, it is best to limit questions while in the presence of the patients. ▪ It is best to just ask your preceptor when it is best to ask questions. o Ask about presentation preference. ▪ You’ll surely be practicing your patient presentation skill before your first rotations. However, what a preceptor wants from a presentation will vary based on the specialty and patient status. ▪ If someone is an established patient coming in for a specific complaint, a problem- focused presentation is appropriate. For a brand-new patient, you’ll want to cover a full history and highlight any items relevant to their presenting complaint. But, without asking, it’s hard to know what your preceptor prefers. ▪ Usually what is most important to the preceptor is that students can determine what is RELEVANT to a patient. They do not have time to sit through an entire medical history on someone they have known for three years and are coming in for a check-up. ▪ Preceptors want to see that students can triage the information they gain from a history and physical and tell the preceptor the essentials for a patient with a certain diagnosis or under a particular treatment.

13 ▪ Please see Three Minute Clinical Presentation Tips in the appendix for further recommendations. o Come ready for the environment. ▪ If you are entering a pediatric rotation, have quick access and be well versed in the treatment of otitis media, pharyngitis, and upper respiratory guidelines. Same if moving into a women’s health rotation – you should have ready access to ACOG pap guidelines and prenatal care recommendations. ▪ Always dress professionally but understanding the environment you will be in will help you to adapt accordingly. For example, high heels may not be the most functional shoes. Please review at length the Graduate Nursing Student Handbook requirements on “Dress Code for Clinical Rotations”. ▪ Pack a lunch and a few extra snacks. You never know what a new rotation may hold in terms of available food or lunch hours. Until you get a lay of the land, bring food with you. ▪ Even if there are places to eat nearby, some practices are too busy to break for lunch. Going on a new rotation is like starting a new job every 5 – 6 weeks and can be mentally exhausting. Do not assume you can make it throughout without some calories. o Honor your role with patients. ▪ One of the most difficult things as a student is not answering a question. ▪ It is in our nature to be helpful. We want to fill in the blanks for patients when they have questions, or sometimes provide a positive spin on something that we probably shouldn’t. ▪ You might be 80% sure of something, but if you are not solid on an answer or feel like you are providing false hope, leave the question for your preceptor. ▪ Clinical rotations are an excellent way to observe how providers handle difficult patient questions. You don’t have to worry about doing this yet, so maintain your role as a student and just learn how you MIGHT handle difficult issues in the future. ▪ Don’t start guessing or talking over your preceptor on diagnosis or treatments. This may cause undo anxiety for the patient and more time than needed by the preceptor to address un-needed concerns. Work with your preceptor on how and when to best discuss student findings and recommendations (either with or without the patient present). o Show up early; stay to the end. ▪ Preceptors understand you have a lot to do in school, but arriving at least 10 minutes early and staying until the work is done (without constant checking of your phone) will go a long way! ▪ You may not be interested in a particular field of study, but there’s always something to learn. Preceptors are always volunteers, so even if you think you would never want to work in their specialty, respect that they are using their time to help you. ▪ Every preceptor is a potential reference and a connection for job hunting in the future. Even if you are bored, or would rather be somewhere else, it’s in your best interest to stay engaged. Don’t get caught with your cell phone causing distractions. Shut it off. Or if needed for entering patient encounters, be certain the provider and staff are aware of

14 how you are using your phone. Many will unfortunately assume other non-student engaged activities. Other Student Clinical Responsibilities When registered in DNP Clinical Courses, the NP student is responsible for: • Following all Graduate Nursing Student Handbook requirements. • Following the administrative policies, regulations, standards, practices (such as universal precautions) and procedures of the contracted (affiliated) clinical facilities. • Safeguarding the confidentiality of client information. • Providing their own transportation to and from the clinical facilities. If a clinical preceptor travels to an outreach site, the student may ride with the clinical preceptor or with facility transportation at their own risk. The University of Mary and Clinical Facility are not responsible should an unforeseen accident occur. • Reporting to the preceptor on time and as scheduled. On time should be 15 minutes prior to the start of the clinical experience. • Providing appropriate and timely notification to Clinical Faculty when conflicts or concerns arise in the clinical setting. This may be a patient, clinical site, preceptor, or variety of other concerns that may interfere with the student’s clinical experience. • Conforming to the standards of professional practice established by the preceptor, affiliated clinical facilities, and any applicable regulating body while participating in the preceptor experience. Understand and practice within the scope of advanced practice nursing as regulated by the Nurse Practice Act in the state where clinical experiences will be completed • Coming prepared to the clinical site with a stethoscope, lab coat, name tag, be ready with EMR access before arriving at clinical. • Wearing a University of Mary identification badge while in the clinical practice area and/or student identification badge per the facilities requirements. • Checking e-mail DAILY. Students registered in NP courses may have short turn-around times for returning needed documents, therefore it is imperative to be checking e-mail accounts frequently. • Keeping course faculty fully appraised of your ability to complete the clinical hours in the expected time frame as clinical contracts do include specific dates. If it becomes apparent to the student or the approved preceptor that the student or preceptor will not be able to meet his/her agreed upon obligations, it is the student’s responsibility to inform the course faculty of the situation to promptly. This allows time to locate an alternative preceptor under whom the expectations can be met or make other arrangements to drop the class or take an incomplete until the course clinical requirements can be completed. • Keeping the FNP clinical faculty, FNP Program Coordinator, and or FNP Clinical Competence Coordinator appraised of any personal crisis that arises that may prevent completion of any courses while attending the University of Mary. All faculty and administrators are well aware that certain situations may arise while students are enrolled in graduate studies and will make every effort to help the student decide what can and should be done about your educational responsibilities at the time of crisis. The key to any sound decision or alternative plan requires that you make the University of Mary aware of your situation. Decisions about tuition refund, dropping a course or courses, taking a leave of absence, obtaining assistance from Student Services can be done in a satisfactory manner when you notify and discuss the situation immediately. • Facilitating a clinical site visit between FNP Clinical Faculty and Preceptor. • Seeing a minimum of one to two patients per hour on most days depending on the complexity of the patient.

15 • Maintaining an accurate and timely electronic clinical log of patient encounters and clinical hours on a weekly basis in the Typhon Clinical Tracking System. Students may be asked to hold on clinical attendance until caught up with clinical work. Typhon Entries must be made for each patient with whom the student has involvement. Entries allow faculty to assess the experience and eventually the competence of the student. Please see Appendix F: Typhon Guidelines/Examples for more detailed information. • Updating NP Clinical Skills Checklist at the end of each clinical course. • Completing the following evaluations in the Typhon Clinical Tracking System: Student Evaluation of Preceptor(s) and Student Evaluation of Clinical Site(s). • Notifying the FNP Clinical Competence Coordinator upon completion of all clinical hours for the course. This allows the FNP Clinical Competence Coordinator to send out the Preceptor and Student Evaluation Forms and a Thank You Letter/Verification of Hours to the Preceptor.

Professional Behavior The highest standard of professional behavior, ethics, and integrity are expected of each University of Mary student. Nurse practitioners have a responsibility for the welfare, well-being, and betterment of their patients, along with a responsibility to maintain their own professional and personal well-being in and out of the clinical setting. Each University of Mary student is expected to treat all fellow course mates, faculty, University of Mary personnel, preceptors, clinical facility staff, and patients with courtesy and respect and with regard for their dignity.

If a student has been found to have fallen short of these expectations (this may include but are not limited to statements of concern for lack of engagement in the clinical experience or professional behavior either verbally or by written evaluation, community complaints of student representation of the University of Mary, alcohol or drug related offenses, disruptive behavior, concerns of any form of harassment), the University of Mary will follow set protocols as found in the Graduate Nursing Student Handbook. The safeguarding of patient care and safety is paramount, and the University of Mary will enforce disciplinary measures to include dismissal from the program whenever necessary and/or if continued behaviors are not resolved.

Please review Graduate Nursing Student Handbook under Principles of Professionalism, Academic and Professional Behavioral Standards Review, Graduate Nursing Academic Progression Committee, and Graduate Nursing Satisfactory Progression.

Establishing Baseline Student Clinical Competence The NP skills checklist is a document utilized to track the clinical skills development of NP students as they progress through the program. The tracking system is started and maintained by each individual student for several reasons. Documentation of skills allows preceptors to assess the level of the student’s experience so that each preceptor can provide a variety of clinical experiences. This snapshot of a student’s abilities and experiences can help to ensure a continuing progression throughout their program of study. Also, as a new graduate, the student will be able to inform potential employers what kind of experience he or she can bring to the table on day one of employment. Overview of Student Clinical Evaluation Methods Course, student, preceptor, and faculty evaluations are an expected part of any clinical experience. These evaluations are important not only because they are required by regional and national accreditation bodies, but also because the evaluations provide information that leads to future improvement of student, program, and the University of Mary. Grading in the clinical courses at a minimum includes consideration of your self- evaluation of clinical objectives, growth of NP Skills, clinical site visits (may be via phone, in-person, other 16 technology-assisted means), clinical logs (through Typhon Clinical Tracking Software), quality of written assignments including dictations, preceptor’s appraisal of your skills, your contributions to group discussions, and your performance in Hotseat Competencies.

On at least three occasions during the FNP program, students will have a formative assessment meeting with the FNP Clinical Competence Coordinator to discuss their current FNP Skills, clinical performance, Hotseat Competencies, and overall clinical competence to update the student, plan further clinical experiences, and/or decide on continued progression through the FNP program. As faculty, we are excited to have this time to work with you one on one as you grow in your professional development!

Clinical Placement Planning Meetings Clinical Placement Planning meetings occur a minimum of three times over the course of the student’s program of study. Members of this meeting include a faculty representative, the Graduate Nursing Clinical Placement Liaison, and the individual student. Meeting occurrences follow the general schedule below: • Meeting 1: January of Year 1 • Meeting 2: September or October of Year 2 • Meeting 3: February or March of Year 2

The purpose of these meetings is to discuss the clinical placement process, develop a clinical placement plan, onboard students to clinical expectations, and determine current stage of clinical competence against expected stage of clinical competence. Students will schedule Clinical Placement Planning meetings through an electronic signup sent to their University of Mary webmail accounts. If the clinical placement plan as minimal changes from the first meeting, Meetings 2 and 3 may be very brief communication completed via phone, email, or face to face during institute sessions.

At least two weeks prior to the first meeting, students must: 1) complete/update/submit a Clinical Placement Information Form, 2) submit a completed NP Skills Check List, and 3) ensure immunization, certification, and background check requirements are up to date in CastleBranch.

NP Skills Checklist While clinical skills may be just one of many abilities needed in today’s healthcare world, they are still extremely important. The NP Skills Checklist is used to help track your progression and exposure to various clinical skills throughout the program. The progression can be shared with FNP Clinical Faculty, your preceptors, and future employers to demonstrate the skills you may need, but more importantly, the skills you have already mastered.

Student Clinical Objectives/Evaluation The student will write individualized clinical objectives to be reviewed and approved by their assigned FNP Clinical Faculty PRIOR to starting the clinical experience. The student is to return a preceptor signed copy of the student’s clinical objectives to clinical faculty preferably within 7 days of starting the clinical experience. At the end of the experience, complete a self-evaluation of your progress related to your specific clinical objectives. This document will serve as an example of your clinical growth throughout each experience.

Clinical Conference Group Meetings Learning in the FNP Program takes many different forms including lecture, lab, and clinical. Your clinical faculty will be monitoring Typhon and clinical dictations. However, direct communication with your clinical faculty is an important factor in the faculty person’s overall assessment of your clinical competence progression.

17 Over the course of the clinical courses there will be at least two meetings to convene with your clinical faculty and small group of peers. These meetings will be placed on the course calendar and will take place via virtual technology. The student is responsible for communicating with their clinical faculty when they believe they have completed their clinical experience. Students will be assigned to reflect on several areas from their clinical experience. Topics that are to be covered will be made available in the course announcements before the first assigned meeting. Students are expected to be full participants. Clinical Site Visit Clinical site visits augment the evaluation process and take place at approximately the midpoint of the student’s clinical hours. The site visits may occur in person, by phone, or virtual technology. During the clinic site visit the FNP Clinical Competence Coordinator will make inquiries related to specific characteristics of the clinical experience and the student’s performance. This visit is further enhanced through direct or technology assisted observation of the student in direct patient care encounters.

Typhon Entries Typhon is a patient tracking system used to document patient encounters throughout clinical experiences. It will be used to track clinical competencies. It can be accessed at https://www.typhongroup.net/np/data/login.asp?facility. University of Mary’s facility number is 7201.

Each student will be provided a user name and password. An orientation is provided prior to the first major clinical experience course. There are student tutorials available for review once a student is logged in. The following are guidelines to follow when using the system. • Clinical schedules must be entered by the student into Typhon as soon as they are established AND NO LESS THAN ONE WEEK PRIOR TO START OF CLINICALS. Students may not start clinicals until their schedule is entered into the Typhon system and their Clinical Objectives have been submitted in Canvas for Faculty Approval. • It is required that all patient encounters be entered. Remember, you are building your database of experiences. You want Typhon to showcase the variety of conditions, diagnostics, pharmacological plans, and procedures that you have had exposure and experience with. The quality of what you put in impacts the quality of the product you will have at the end. It should be your goal to maximize this tool’s potential as a professional marketing portfolio for you in the future. Clinical logs must be completed on a WEEKLY basis, however it is highly recommended that students enter encounters daily. All entries of patient encounters from the previous week must be entered in Typhon by Monday of each week! Should students become more than 1 week behind on Typhon entries, they will not be allowed to continue with the clinical experience until caught up.

Dictations The purpose for evaluation of dictations/documentations is to appraise your critical thinking skills as well as your proficiency regarding assessment, diagnosis/impression, and development of a plan of care. In addition, assessments of clinical documentation assists with quantification of a student’s ability to formulate an accurate, clear, well organized record that reflects and facilitates sound clinical thinking. If at all able, do take the opportunity to document for your preceptors. However, ALL dictations submitted for grading must be self- typed and submitted in a word document. No COPIED or facility-based dictations are allowed. Be sure your dictations are complete but scrubbed of any patient identifying information (birthdate, medical record numbers, names, etc.). This assignment is a learning tool. Specific rubric criteria for each clinical course will be provided. Although various clinical sites may use a different format and or electronic templates, the student 18 must follow University prescribed dictations. For example, some clinical sites will note “All systems negative” or Cardiovascular Assessment is negative. This will not suffice for program requirements because FNP Clinical Faculty are assessing your ability to include pertinent information, exclude unneeded elements, complete and document appropriate physical exams using medical terminology. Therefore, students will be required to write out full review of systems and exam findings.

Preceptor Typhon Evaluations At the end of the clinical experience an electronic evaluation is completed by each preceptor using the Clinical Evaluation form located in NPST/Typhon. This evaluation is essential for educational and evaluation processes. Preceptors are encouraged to discuss the evaluation with the student prior to its completion. Preceptors are expected to intervene directly and immediately should the student provide unsafe or inappropriate care in the clinical facility. Students are encouraged to save their Typhon evaluations after each clinical rotation because it demonstrates your competence and can be helpful for future employment. It offers a skills report of your clinical.

Hotseat Competency Testing Student clinical competence is further evaluated by faculty during practical testing that occurs on campus at the conclusion of each clinical course. Using a simulated scenario, the student is evaluated on their history, physical exam, clinical decision making, diagnosis, management, and patient education competence. This competency testing is coined “hot seat” because they are evaluated in real time by at least two faculty while also being observed by their peers. This is a Pass/Fail requirement for continued progression in the FNP Program. If a student fails the Hotseat Competency, several other factors are taken into consideration. Based on an overall assessment of the student’s performance in the clinical setting and FNP course work, students may be required to repeat the course, repeat another Hotseat Competency, complete additional clinical hours, or work one on one with faculty followed by another Hotseat Competency. The final recommendation will be made based on feedback from at least two clinical faculty. Please see Appendix J for further information.

19 Appendix A Graduate Nursing Student Health Requirements

GRADUATE NURSING STUDENT HEALTH REQUIREMENTS

It is the responsibility of the graduate nursing student to comply with the following requirements and provide documentation of all required immunizations to the Graduate Nursing Program at least one full semester prior to any course with a clinical experience (this includes non-direct patient care experiences). Immunization records must be provided on letterhead or other form clearly labeled with the name of the provider or agency who administered the immunizations. Positive titers are acceptable evidence of immunity status.

Healthcare agencies that the student participates in clinical experiences have similar requirements. Failure to meet these expectations will prevent the student from entering a clinical experience. Instructions: 1. All items listed, with the exception of Hepatitis B, are MANDATORY FOR ALL STUDENTS. Only persons born before January 1, 1957 are exempt from having to submit this information. 2. Persons born before January 1, 1957 must submit a copy of a valid driver’s license, passport, or birth certificate to establish proof of age. 3. Please label all pages of immunization records with appropriate identification including your current name if it is different from what is on the record.

Immunizations Required Influenza Vaccine Submit proof of influenza vaccine within the last year Tetanus-diphtheria (Td or Tdap) Submit proof of a tetanus booster which is less than 10 years old Rubeola (provide ONE of the following) Submit dates of immunization with live virus vaccine (if born after 1968 proof of TWO doses required) Submit blood titer results proving immunity Mumps (provide ONE of the following) Submit date of immunization with live virus vaccine Submit blood titer results proving immunity Rubella (provide ONE of the following) Submit dates of immunization with live virus vaccine Submit blood titer results proving immunity Varicella (provide ONE of the following) Submit dates of immunization Submit blood titer results proving immunity Tuberculin skin test (TB or PPD) Submit documentation of one of the following: 1. initial two step TB test and annual PPD within the last 12 months 2. results from T-SPOT.TB within the last 12 months 3. results QuantiFERON (QFT) within the last 12 months 4. results of either an initial T-SPOT.TB or QuantiFERON (QFT) and PPD within the last 12 months Students with a positive past TB skin test must complete the annual TB questionnaire initially and annually, while enrolled. While enrolled, annual PPDs, T-SPOT.TB, or QuantiFERON results are required. Hepatitis B Although not required, Hepatitis B vaccination series is highly recommended. If completed submit dates of immunization or submit serology proving immunity. Students who chose not to receive the vaccine must sign a form indicating they are familiar with the risks and decline the vaccine.

20

21 Appendix B NP Skills Checklist

The student should update and share the Family Nurse Practitioner Student Skill Set with their assigned preceptor at the beginning of each clinical experience. This document is meant to help preceptors understand the student’s degree of experience with skills identified in the document below.

Student Name: Date: Phone: Email:

Current Term of Study: Course Title: Total Hours Required for this Clinical Placement: Total Hours Required for the Clinical Course this Semester: Total Clinical Hours Completed Prior to beginning this experience: Total Clinic Hours Required for Program:

Current Computer Skills: Brief Background of Nursing Experiences/Specialty Areas: Certifications:  Epic  BLS  McKesson  PALS  Cerner  ACLS  Meditech  ATLS  Dragon Dictation  Other ______ EClinical Works  Word  Excel  Other______

The responses below represent a self-reflection of degree of past experience and current comfort level for each skill: General Nurse Practitioner Skills

Past Experience Current Comfort Level 1. No Experience 1. Not Comfortable Skill 2. Learned in Class/Observed in Clinical 2. Limited Comfort 3. Practiced in Lab 3. Comfortable 4. Performed in Clinical Setting 4. Very Comfortable Obtain Complete Health 1 2 3 4 1 2 3 4 History Perform Complete 1 2 3 4 1 2 3 4 Physical Exam Order/Perform 1 2 3 4 1 2 3 4 Diagnostic Tests Interpret Clinical 1 2 3 4 1 2 3 4 Findings Develop Differential 1 2 3 4 1 2 3 4 Diagnoses Develop Health Care 1 2 3 4 1 2 3 4 Problems List Develop/Implement 1 2 3 4 1 2 3 4 Plan for Patient Arrange 1 2 3 4 1 2 3 4 Referrals/Consults Authorize/Coordinate 1 2 3 4 1 2 3 4 Admission 22 Authorize/Coordinate 1 2 3 4 1 2 3 4 Discharge Prescribe Specific 1 2 3 4 1 2 3 4 Medications Prescribe Specific Therapeutic 1 2 3 4 1 2 3 4 Interventions Develop/Implement 1 2 3 4 1 2 3 4 Health Promotion Plan Develop/Implement 1 2 3 4 1 2 3 4 Illness Prevention Plan Develop/Implement 1 2 3 4 1 2 3 4 Injury Prevention Plan Provide Patient 1 2 3 4 1 2 3 4 Education & Counseling Document to 1 2 3 4 1 2 3 4 Established Standards Assign Appropriate ICD 1 2 3 4 1 2 3 4 10 Billing Codes Participate in Quality 1 2 3 4 1 2 3 4 Assurance Activities Participate in Risk 1 2 3 4 1 2 3 4 Management Activities Participate in Research 1 2 3 4 1 2 3 4 Activities Policy and Procedure 1 2 3 4 1 2 3 4 Development Promote Evidence Based 1 2 3 4 1 2 3 4 Practice Dictate 1 2 3 4 1 2 3 4

General Minor Surgery

Past Experience Current Comfort Level 1. No Experience 1. Not Comfortable Skill 2. Learned in Class/Observed in Clinical 2. Limited Comfort 3. Practiced in Lab 3. Comfortable 4. Performed in Clinical Setting 4. Very Comfortable Preoperative 1 2 3 4 1 2 3 4 Assessment Debridement of Wound 1 2 3 4 1 2 3 4 Select Digital Nerve

Block Incision and Drainage 1 2 3 4 1 2 3 4 Suture 1 2 3 4 1 2 3 4 Staple 1 2 3 4 1 2 3 4 Staple/Suture Removal 1 2 3 4 1 2 3 4 Drain Removal 1 2 3 4 1 2 3 4 Hemorrhoid Lancing 1 2 3 4 1 2 3 4 Use of Venous Doppler 1 2 3 4 1 2 3 4 Use of Cryotherapy 1 2 3 4 1 2 3 4 Assist in Surgery 1 2 3 4 1 2 3 4

23 Orthopedic

Past Experience Current Comfort Level 1. No Experience 1. Not Comfortable Skill 2. Learned in Class/Observed in Clinical 2. Limited Comfort 3. Practiced in Lab 3. Comfortable 4. Performed in Clinical Setting 4. Very Comfortable Remove External 1 2 3 4 1 2 3 4 Fixators with Pin Instruct Crutch Walking 1 2 3 4 1 2 3 4 Cast 1 2 3 4 1 2 3 4 Splint 1 2 3 4 1 2 3 4

Arthrocentesis 1 2 3 4 1 2 3 4

Interpret Basic Orthopedic X-rays  Spine 1 2 3 4 1 2 3 4  Upper Extremity 1 2 3 4 1 2 3 4  Pelvis 1 2 3 4 1 2 3 4  Lower Extremity 1 2 3 4 1 2 3 4

Cardiac/Pulmonology

Past Experience Current Comfort Level 1. No Experience 1. Not Comfortable Skill 2. Learned in Class/Observed in Clinical 2. Limited Comfort 3. Practiced in Lab 3. Comfortable 4. Performed in Clinical Setting 4. Very Comfortable Distinguish Type of 1 2 3 4 1 2 3 4 Pacemaker Perform/Interpret 12- 1 2 3 4 1 2 3 4 lead EKG Instruct Use of Incentive 1 2 3 4 1 2 3 4 Spirometer Interpret Pulmonary 1 2 3 4 1 2 3 4 Function Testing Interpret Chest X-ray 1 2 3 4 1 2 3 4 Interpret ABG’s 1 2 3 4 1 2 3 4 Educate Use: MDI; 1 2 3 4 1 2 3 4 Aerochamber; Peak Flow Meter

Gynecology/Urology

Past Experience Current Comfort Level 1. No Experience 1. Not Comfortable Skill 2. Learned in Class/Observed in Clinical 2. Limited Comfort 3. Practiced in Lab 3. Comfortable 4. Performed in Clinical Setting 4. Very Comfortable Obtain Fetal Heart 1 2 3 4 1 2 3 4 Tones Obtain Pap Smear 1 2 3 4 1 2 3 4 Interpret Wet Prep 1 2 3 4 1 2 3 4 Microscopy 24 Obtain Vaginal Cultures 1 2 3 4 1 2 3 4 Obtain Group B Strep 1 2 3 4 1 2 3 4 Culture Obtain Post Void 1 2 3 4 1 2 3 4 Residual

Dermatology

Past Experience Current Comfort Level 1. No Experience 1. Not Comfortable Skill 2. Learned in Class/Observed in Clinical 2. Limited Comfort 3. Practiced in Lab 3. Comfortable 4. Performed in Clinical Setting 4. Very Comfortable Shave Biopsy 1 2 3 4 1 2 3 4 Punch Biopsy 1 2 3 4 1 2 3 4 Excision Biopsy 1 2 3 4 1 2 3 4 Wart Cryotherapy 1 2 3 4 1 2 3 4

Miscellaneous

Past Experience Current Comfort Level 1. No Experience 1. Not Comfortable Skill 2. Learned in Class/Observed in Clinical 2. Limited Comfort 3. Practiced in Lab 3. Comfortable 4. Performed in Clinical Setting 4. Very Comfortable Eye Fluorescein Stain 1 2 3 4 1 2 3 4 Corneal Abrasion ID 1 2 3 4 1 2 3 4 Removal of Foreign Body:  Eye 1 2 3 4 1 2 3 4  Nose 1 2 3 4 1 2 3 4  Ear 1 2 3 4 1 2 3 4

Ingrown Toe Nail 1 2 3 4 1 2 3 4 Removal Audiometry 1 2 3 4 1 2 3 4 Interpretation Other______1 2 3 4 1 2 3 4

25 Appendix C Clinical Placement Information Form Graduate Nursing: Clinical Placement Information

First Name Last Name Previous/Maiden Name

Current Street Address

Address Line 2

City State/Province/Region

Postal/Zip Code Country

Email

Phone Number for Facilitating Clinical Placement ( )

Any possible city or state movements during the program?  NO  YES Please Describe

Current Employer

Current Employer Street Address

Address Line 2

City State/Province/Region

26 Postal/Zip Code Country

Hometown City Hometown State

I have family or friends that I can stay within the following cities:

Potential Preceptors and Clinical Sites (List any and all possibilities including specialties):

Previous Place of Employment

Last Date Employed at Previous Employment Site

Address Line 2

City State/Province/Region

27 Postal/Zip Code Country

I have work experience or professional interests in the following areas:  Med-Surg  Family Medicine  Internal Medicine  Orthopedics  Mental Health  OB/GYN  Pediatrics  ICU  Emergency Medicine  Urgent Care  Hospital Medicine  Rural Health  Pain Management & Rehabilitation  Oncology  Surgery  Cardiovascular

Any additional notes or comments that may help facilitate scheduling clinical experiences:

28 Appendix D Student Clinical Practice Contract/Objective and Evaluation Example Clinical Practice Contract Pass/Fail

Directions: Complete the following Clinical Practice Contract for all four semesters of 759, 859, 869, and 960. This document will need to be updated each semester.

Clinical Contract Purpose: The clinical contract represents the student's personal objectives for clinical learning and should be a reflection the overall program/course objectives. Prior to beginning the clinical experience, the student will author clinical activities and a clinical objectives evaluation plan. At the conclusion of the clinical experience, the student will complete this document with an evaluation of their achievement of the identified clinical objectives.

The Clinical Practice Contract (minus the clinical evaluation) should be completed prior to the beginning of your clinical experience and must be approved by your designated clinical faculty for that course.

Process: This contract should be completed prior to the beginning of your clinical experience and approved by designated faculty. After forming a professional draft of this contract, consult with designated faculty to identify if there are needed edits or opportunities for improvement. Make those changes as appropriate, sign the document, have your preceptor sign the document, and then turn it into the drop box by the due date indicated on the course calendar. The instructor will have final approval authority for your contract.

Clinical Learning Objectives: Define your overall focuses for the course.

Clinical Activities to Achieve Objectives: Description of your plan to meet the objectives. How will the objectives be carried out and with whom? Try to make them measurable so evaluation can be objective.

Clinical Evaluation Plan: Description of your plan for evaluation of your progress in meeting your objectives/clinical activities.

Clinical Evaluation Summary: Broad statement of how your activities for the semester were met.

29 EXAMPLE - Clinical Practice Contract POINTERS: Clinical Learning Objective 1 should flow with the Clinical Activities 1, Clinical Evaluation Plan 1, and Clinical Evaluation Summary 1. Note how the Clinical Activities and Clinical Evaluation Plan provide MEASUREABLE and REALISTIC tasks and outcomes. This will significantly improve your ability to fully evaluate the meets or does not meet for each of your objectives. This document needs to be approved by both your clinical faculty and preceptor. This should serve as a talking tool with your preceptor in regards to how you learn best. Be sure to ask for feedback and modify based on your preceptors willingness to follow through with your plan or if they have recommended changes based on how the preceptor prefers to assist with advancing your skills. The Clinical Activities and Evaluation Plan may also need modification depending on what is realistic with that specific clinical environment. Name: Course Number: Credits/Hours: Semester/Year:

NUR 759 Program Year 2/Primary Care Clinical Clinical Learning Objectives: (Address the Clinical Activities Clinical Evaluation Plan: Clinical Evaluation Summary following elements) (How, with whom): 1. Request feedback from my (Complete at end of ASSESSMENT 1. Collect at least 1-3 histories per preceptor regarding my semester): - History-Subjective Data clinical day under the direction of competence on history taking after 1. My preceptor was not 1. Increase my competency in collecting my preceptor. every two clinical days of active present for the majority of thorough histories based upon patient 2. Perform at least one focused participation. histories that I collected, but complaint. and at least one comprehensive 2. Request feedback from my simply heard my reports. He - Physical – Objective Data physical examinations per clinical preceptor regarding my denied any area for 2. Increase my competency in performing day as indicated by the patient competence on performing improvement. a comprehensive physical examination complaint under the supervision comprehensive physical 2. While I performed various using accurate, evidence-based of my preceptor. examinations after every two comprehensive examinations, techniques. 3. Identify at least one health clinical days of active participation. my preceptor was not present - Health Promotion & Risks promotion/preventive activity per 3. Review with preceptor personal to observe my technique and 3. Identify health and psychosocial risks patient (immunizations, tobacco, understanding of recommended critique my skills. However, he when implementing treatment plan. exercise, preventive screening, health promotion/preventive reported that my assessments - Differential Diagnosis etc). activities for at least 2 patients were accurate, and assisted 4. Gain experience in creating a list of 4. Generate at least four each clinical day. me with techniques when I differential diagnoses as indicated by the differential diagnoses per 4. Verify my list of differential was uncertain. patient’s presenting problem. presenting problem for the diagnosis with my preceptor on at 3. My preceptor stated that patients I see on clinical days. least 1 – 2 patients per clinical day. there was no specific area in MANAGEMENT 5. Analyze the information 5. Verify correct interpretation of which I need improvement—I - Clinical Reasoning received from each physical patient case, diagnostics, and just need experience. 5. Demonstrate skill in interpreting examination, health history, and management plan with preceptor Preceptor noted I was pertinent biopsychosocial evidence laboratory/diagnostic studies for on at least 3 patients a day. appropriately applying the US derived from individual and family at least 2 patients per clinical day Preventive Service Guidelines assessments including health histories, of active participation, suggesting for patients reviewed. 30 physical examinations, laboratory and proposed diagnoses based on 6. Verify appropriateness of 4. Many of the patients I saw diagnostic sources, and current literature. these findings. recommended diagnostic tests for presented for established - Diagnostic Strategies & Interpretation 6. Order at least two diagnostic each patient with preceptor. conditions, decreasing the 6. Order and interpret appropriate tests per day if indicated by a 7. Suggest appropriate need for developing diagnostic tests for patients based on patient’s examination findings and pharmacologic and non- differential diagnoses. Thus, I history and physical findings. personally review the laboratory, pharmacologic interventions for at developed little practice in - Patient Care Management ECG, and imaging results of each least two patients per clinical day. this regard. However, there 7. Demonstrate competence in developing patient I work with, consulting my Verify appropriate dosing and were several occasions where appropriate treatment plans in order to resources, such as Epocrates, indications with preceptor. I suggested possible diagnoses provide patient-centered, evidence-based Nursing Central, Squire’s 8. Request feedback from for my preceptor to verify. care. Radiology, and UpToDate, as preceptor regarding my Will need to continue working - Documentation & Presentation needed to increase my performance in providing both oral on this skill. 8. Present assessment data, both orally understanding. and written assessments every two 5.6. &7. The management and written, in an organized manner. 7. Formulate management plans clinical days of active participation plans for my patients were -Patient & Family Relationships based on current evidence, and for each dictation completed. developed primarily by my 9. Establish a relationship with the utilizing resources such as 9. By the end of the rotation preceptors. However, I would patient/family characterized by mutual UpToDate, Epocrates, etc., for at request feedback from preceptor question them at times, or respect, empathy, and cultural least two patients per clinical day regarding my interactions with suggest other strategies. For instance, if a diabetic patient considerations. of active participation. patients and family members. presented with multiple - Evaluation 8. Orally inform my preceptor 10. Discuss with preceptor possible cardiac risk factors, I would 10. Participate in review of patient regarding the history, physical, impact of life transitions and health suggest that we have the outcomes and follow through. and examination findings of each status on patient outcomes for at patient begin taking low-dose - Patient Education patient I see independently. least 2 patients per clinical day. aspirin. Thus, my skills have 11. Provide anticipatory guidance that is Complete at least five dictations 11. By the end of the rotation, grown in this area, but I have age, developmentally, and culturally on patients throughout the clinical request feedback from preceptor much room for improvement. appropriate to assist the client in assuming experience. regarding ability to provide 8. My preceptor reported that responsibilities for self-care and health- 9. Collaborate with patient/family appropriate patient education and my oral presentations and promotion such as healthy nutritional and in decision making for patient discharge planning charting was “fine,” but physical activity practices. centered care. recommendations. encouraged me to become

10. Consider possible impact of 12. By the end of the rotation, more concise in my notes. By LEADERSHIP & PROFESSIONAL ROLE life transitions and health status request feedback from preceptor the end of the experience, I - Accountability & Professionalism on patient outcomes for each and other clinical staff regarding did all the charting for the HPI, 12. Demonstrate accountability for own patient. professional behavior and ROS, and physical learning and professional behaviors 11. Provide anticipatory guidance encourage preceptor and other examinations for the patients I (punctuality, confidentiality, respect, and regarding nutrition, physical staff to correct me early if any saw. I feel that I have fully met communication). activity, and developmental 31 - Role & Healthcare Systems expectations for each patient seen concerns noted throughout the this objective but will continue 13. Identify roles of interprofessional in clinic. experience. to advance with experience. healthcare members in delivery of 12. Arrive prepared and in 13. Discuss with preceptor roles of 9. Received positive specialty services to provide a continuum appropriate clinical dress at least interprofessional healthcare compliments from patients, of patient care. 15 minutes prior to start of clinical members in delivery of specialty “She did a good job.” day. services for at least one patient per Preceptor noted patients were 13. Consider roles of clinical day. comfortable with me and I interprofessional healthcare was able to develop a quick members in delivery of specialty rapport with patients and services for each patient as family members. indicated throughout the clinical 10. Able to discuss potential experience. impact of planned treatment protocol for each patient throughout the clinical experience with the preceptor and or clinic nurse. 11. Always asked by preceptor when each patient needed to return for follow-up or next evaluation. By the end of the rotation, preceptor did not have to correct my recommendations. 12. Positive feedback received from clinic staff and preceptor. Noted I was a “joy to work with” and appreciated for “working so hard, coming early, and staying to the end.” 13. Able to spend time with radiologist, physical therapist, and occupational therapist for about 1 hour each during clinical experience. Preceptor feels it is imperative to provide patient care as a team 32 and know/understand the various roles. Whenever a patient required additional team care, discussed purposes and to request specific actions or consult required. Also advised to review expectations with the patient so that they are prepared as well.

NUR 859 Program Year 2/Women and Children Clinical Clinical Learning Objectives: Clinical Activities Clinical Evaluation Plan: Clinical Evaluation Summary (Address the following elements) (How, with whom): (Complete at end of ASSESSMENT semester): - History-Subjective Data - Physical – Objective Data - Health Promotion & Risks - Differential Diagnosis MANAGEMENT - Clinical Reasoning - Diagnostic Strategies & Interpretation - Patient Care Management - Documentation & Presentation -Patient & Family Relationships - Evaluation - Patient Education LEADERSHIP & PROFESSIONAL ROLE - Accountability & Professionalism - Role & Healthcare Systems

NUR 869 Program Year 2/Special Populations Clinical

33 Clinical Learning Objectives: Clinical Activities Clinical Evaluation Plan: Clinical Evaluation Summary (Address the following elements) (How, with whom): (Complete at end of ASSESSMENT semester): - History-Subjective Data - Physical – Objective Data - Health Promotion & Risks - Differential Diagnosis MANAGEMENT - Clinical Reasoning - Diagnostic Strategies & Interpretation - Patient Care Management - Documentation & Presentation -Patient & Family Relationships - Evaluation - Patient Education LEADERSHIP & PROFESSIONAL ROLE - Accountability & Professionalism - Role & Healthcare Systems

NUR 960 Program Year 3/Seminar and Practicum Clinical Learning Objectives: Clinical Activities Clinical Evaluation Plan: Clinical Evaluation Summary (Address the following elements) (How, with whom): (Complete at end of ASSESSMENT semester): - History-Subjective Data - Physical – Objective Data - Health Promotion & Risks - Differential Diagnosis MANAGEMENT - Clinical Reasoning - Diagnostic Strategies & Interpretation - Patient Care Management - Documentation & Presentation -Patient & Family Relationships - Evaluation - Patient Education LEADERSHIP & PROFESSIONAL ROLE 34 - Accountability & Professionalism - Role & Healthcare Systems

I agree to accept the responsibility of fulfilling this agreement.

Student Signature: ______Date: ______

*******************************************************************************************************

I agree to accept the responsibility of serving as the preceptor. I have reviewed Clinical Scholarship Practice Contract developed by this student and am in agreement with the objectives sought. I have verified that an institutional contract is concurrent for this experience.

Preceptor Name (typed): ______

Preceptor Signature: ______Date: ______

35 Appendix E 3 Minute Clinical Case Presentation

The ability to deliver short and succinct oral case presentations is a core skill for any provider. Effective oral case presentations help facilitate the transfer of information among providers and are essential to delivering quality patient care. Oral case presentations are also a key component of how students are assessed during their clinical experiences. Displays how much the student knows and or doesn’t know for future learning.

At its core, an oral case presentation functions as an argument. It is the job of the presenter to share the pertinent facts of a patient’s case with other members of the medical care team and establish a clear diagnosis and treatment plan. Thus, the presenter should strive to include details to support the proposed diagnosis and argue against alternative diagnoses, and exclude extraneous information. While this task may seem daunting at first, with practice, it will become easier. That said, if you are unsure if a particular detail is important to your patient’s case, it is probably best to be safe and include it.

During your clinical experiences, you and in particular your preceptor, do not have the time for lengthy presentations of every detail. The following framework below can be applied to patients in most settings with slight modifications.

STYLE As the presenter, strive to deliver an interesting presentation that keeps your preceptor or other team members engaged: • Be Confident o Speak clearly at the loudest volume appropriate to protect patient privacy, vary your tone to emphasize the most important details, and maintain eye contact. • Minimize Fidgeting o Stand up straight and avoid unnecessary, distracting movements. • Use Your Notes; But Avoid Just Reading o Glance at your notes, but there is no better way to lose your preceptor’s attention than to simply read your notes to them. • Be Honest o Given the importance of presentations in guiding medical care, never report false information to the team. If you are unsure about a particular detail, it is fine to say so. DON’T GUESS!!

LENGTH The length of your presentation will depend on a variety of factors, including the complexity of your patient, your audience, and the specialty covering. For an outpatient family practice clinic, you should strive for 2 – 5 minutes. Ideal length should be 3 minutes.

STRUCTURE Expectations may vary among preceptors for patient presentations, so either before your first patient or after your first time delivery, check in with the preceptor to identify how they would prefer you best present a patient. Once you have presented, check in to identify any recommendations for change.

PRESENTING THE PATIENT

1. Opener a. Every oral presentation should begin with a brief one-liner that contains the patient’s name, age, relevant past medical history, and chief complaint. Remember the chief complaint is the reason that the patient sought medical care in his or her words. Example: “Ms. Green is a 78 year old 36 female with a past history of COPD who presents to the clinic after noting increased productive cough and shortness of breath at home.” b. If the patient is a female presenting for a GYN complaint, the opening should include gravida para status. Example: “Ms. Joe is a 44 year old G4P4 previously healthy female patient presenting with heavy vaginal bleeding for the last 3 weeks.” c. For a young child consider the following: “Emma is a developmentally normal 15 month-old female without previous congenital or chronic disease presenting with nasal drainage and cough for 10 days, now with fever of 102.” Or: “Tigen is a 10 month old male patient with down’s syndrome presenting with a 5 day history of nasal and eye drainage.” d. Introductory sentence: Mr./Mrs./Ms.____ was in his/her usual state of ____ (e.g., excellent health/poor health) until ____(e.g., three days prior to admission) when he/she developed the ___ (acute/gradual) onset of _____. The introductory sentence may include details of past medical history if the patient’s illness directly relates to an ongoing chronic disease. e. Don’t mention that an event occurred “on Saturday”, rather refer to the time relative to the day of presentation, e.g. 3 days ago... f. Other Good Examples: “Mr. Smith is a 55 year-old man with a long history of diabetes mellitus, cirrhosis, and chronic obstructive lung disease, who presents with a chief complaint of fever and productive cough…”; “Mrs. Jones is a 39 year-old woman who was electively admitted for evaluation of exertional dyspnea. Her active problems include rheumatoid arthritis and hypertension. She was in her normal state of health until…” g. Comparison of Bad/Good Examples: BAD: “…his problem list includes coronary artery disease – myocardial infarction x 2, the last in 1996, multiple negative rule-outs since, ejection fraction equaled 35% in 1994; diabetes mellitus x 10 years, insulin requiring for five years, complicated by retinopathy; chronic obstructive lung disease – with a FEV1* of 1.2 liters and steroid dependence…” GOOD: …his active problems include coronary artery disease, diabetes mellitus, and chronic obstructive lung disease…. In the Bad Example the listener will forget the chief complaint by the time you reach the history of present illness. The Good Example is concise and does not interrupt the listener’s train of thought between the chief complaint and the history of present illness; relevant information about each of these problems should be introduced when appropriate in the “HPI” or “other medical problems.”

2. History of Present Illness a. Following the opener, elaborate on why the patient sought care. Describe the events that preceded the patient’s presentation in chronological order. OPQRST or OLDCARTS are very helpful here. b. OPQRST i. Onset of patient’s symptoms; ii. Palliative or Provoking factors that make symptoms better or worse; iii. Quality of symptoms (how the patient describes the symptoms); iv. Region of the body where the patient is experiencing concern and if the symptoms is pain, whether the pain Radiates to another location or is well localized; v. Severity of the symptoms and any other associated Symptoms; vi. Time course of the symptoms (how they have changed over time and whether the patient has experienced them before. c. OLDCARTS i. Onset ii. Location/radiation iii. Duration iv. Character v. Aggravating Factors 37 vi. Relieving Factors vii. Timing viii. Severity d. Include any other details that may support your final diagnosis or rule out alternative diagnosis. For example, if concerned about a pulmonary embolism and patient had a recent long-distance flight, then that would be worth mentioning. e. Good Examples: “Mr. Smith has a long history of chronic obstructive lung disease characterized by two block dyspnea on exertion, FEV1 of 1.0 liter, and home oxygen therapy. He was in this usual state of health until three days ago when he developed the gradual worsening of his shortness of breath, associated with a cough productive of yellow sputum and a fever of 102”. “Mr. White has a long history of coronary artery disease characterized by three myocardial infarctions, the most recent in 1995, ventricular tachycardia treated with amiodarone, and congestive heart failure. He was in his usual state of health, with angina occurring once per week, until last night, while watching a football game, he developed the acute onset of severe substernal chest heaviness…” f. Bad Example: A poorly characterized and too brief history of present illness: “Elderly man presents for evaluation of chest pain. He was well until three weeks ago when he began to feel chest heaviness whenever he exerted himself. He saw his local doctor who prescribed antacids with little benefit. The pain woke him last night so he came back to the clinic today for evaluation. His other problems include…….” A more complete example: “72 year old previously healthy male presents for evaluation of chest pain. He was in his usual state of excellent health until three weeks ago when he started developing the gradual onset of intermittent chest pain, characterized as poorly localized deep substernal heaviness which radiated to his left shoulder, lasting about five minutes per episode, occurring several times a day, aggravated by exertion and relieved by rest. Associated with the pain were shortness of breath and nausea. One week ago he was seen by a local doctor who, without other testing, diagnosed gastritis and prescribed antacids without benefit. The chest pain was stable until two hours ago, when he awoke with a more severe version of the same pain that lasted until he presented here to the clinic. Currently at rest he has no pain. There is no history of cough, heartburn, weight loss, or fever, chills or sweats. The patient’s risk factors for coronary artery disease include a positive family history and a cholesterol of 310 in 1998. He has no history of high blood pressure or diabetes and has never smoked cigarettes.”

3. Review of Systems a. The review of systems is sometimes included in the history of present illness, but may also be separated. Given the potential breadth of the review of systems (meaning a comprehensive list of questions that may be asked), when presenting, ONLY report information that is relevant to your patient’s condition. Most commonly the information provided in the HPI is all that is needed for your initial 3 minute presentation.

4. Past Medical History a. This should include any additional medical history that was not highlighted in the opener, but pertinent to the chief complaint to include other chronic medical problems; recent or past surgeries; past or recent hospitalizations, ER visits, or clinic visits; current medications or recently discontinued medications; and allergies. If no pertinent past medical history information is pertinent, it is acceptable to note: “No significant past medical or surgical history”. Or past medical and surgical history is non-contributory.” b. Example: “…his other medical problems include insulin-requiring diabetes for 12 years, complicated by retinopathy, polyneuropathy, and nephropathy. His recent creatinine was 1.7…” 38

5. Family History a. Relevant family history should include any relevant conditions that run in the patient’s family, with an emphasis on first-degree relatives.

6. Social History a. Pertinent information may include living situation, occupation, alcohol and tobacco use, other substance use. b. You may also need to include relevant details about the patient’s education level, travel history, history of animal and occupational exposures, and religious beliefs. For example, it would be worth mentioning that your anemic patient is a Jehovah’s Witness to guide medical decisions regarding blood transfusions. c. It is often the social history that explains why the patient has fallen ill now, as opposed to some other time or not at all: patients may have chaotic lives and little social support so don’t have the help they need to follow therapeutic recommendations, few financial resources and can’t afford their meds, depression and feelings of hopelessness about their conditions, etc. These factors, if not addressed, will tend to lead to rehospitalizations. If appropriate, include information about the patient’s personal wishes for health such as advance directives (their living will and durable power of attorney) including discussion concerning these issues.

7. Physical Exam a. Start with vital sign’s including Temperature, Heart Rate, Blood Pressure, Respiratory Rate, and Oxygen Saturation. Include postural changes when relevant. b. Include pertinent findings of your physical exam, including general impression of the patient (including whether they appear “sick” or not). Depending on the “system” affected, you will want to include specific areas again based on the chief complaint. For example, for chief complaint of cough – will need to include a minimum of HEENT, Respiratory, Cardiovascular, Abdomen, and Extremities. c. General description – be colorful, allow the listener to visualize the patient. “The patient was short of breath” is inferior to “the patient was sitting on the edge of the bed, leaning forward and gasping for breath.” d. Mention only the relevant positive findings and relevant negative findings. e. Use concise but complete descriptions of positive findings. Resist the urge to report an exam as being “normal”. Instead, report your findings in medical terminology. For example, if a patient presents with chief complaint of “abdominal pain” and the exam is currently normal, should report “the patient’s abdomen is soft, non-tender, and nondistended, with normoactive bowel sounds. No guarding or rebound tenderness is present. No CVA tenderness.”

8. Any known lab findings past or recent pertinent to the current problem a. If any previous labs, imaging, or other diagnostics were obtained pertinent to your diagnosis (such as with a recent ER visit or hospitalization), these could be included here. You do not have to report the results of every test that was ordered.

9. Assessment a. This is the most important part of your presentation and gives you the opportunity to show your preceptor how much you really know. b. Provide 3 – 5 of the most possible differential diagnosis, but then note your most likely diagnosis and what further diagnostics one should consider to validating this diagnosis.

39 c. Explain why you think each diagnosis is or is not the final diagnosis. Be sure to rule out potentially life-threatening conditions (unless you think your patient has one). For the COPD patient previously noted above you may need to note why you don’t believe the symptoms are due to congestive heart failure or a pulmonary emboli. d. Consider the following format: “…the patient’s major presenting problem is ____ (best positive statement you can make; say “chest pain” and avoid statements like “rule-out myocardial infarction”). The differential diagnosis includes ____, ______, and _____. The diagnosis of _____appears to be the most likely of these because ______. e. Example: “...the patient’s main problem is chest pain, which could be due to a myocardial infarction, a dissecting aortic aneurysm, pericarditis, and a variety of other diagnoses such as pneumonia, pulmonary embolus, or esophageal disease. MI seems most likely, because his description of chest pain is classic for angina and because his ECG reveals a new injury current in the inferior leads.” f. While your assessment can be similar to your opener, is should not be identical: “Ms. Joe is a 78 year old female with past history of COPD presenting with SOB and cough in the setting of a URI who is now stable on 2 liters of supplemental oxygen delivered via nasal cannula. Symptoms thought to be secondary to an acute exacerbation of COPD.” “There is no previous history of CAD, denies chest pain, fever. No evidence of fluid overload. Negative for PE risk factors including recent travel, previous DVT/PE, estrogen exposure, recent surgery, or known clotting disorder for the patient or in immediate family members. Grandchildren have been staying with patient and have been ill with URI symptoms.” g. If the diagnosis is apparent just based on history and exam, then include the supporting diagnostic criteria. For example: “Most likely diagnosis is a bacterial sinus infection based on 14 day history of mucopurulent nasal drainage, nausea, bilateral maxillary sinus tenderness, cough, that is not relieved with 5 days of continued antihistamine and decongestants.”

10. Recommended Plan of Action. a. Include additional studies for supporting or ruling out diagnosis. If known diagnosis, include your treatment plan, education, and follow-up recommendations. Example for sinusitis patient: “Patient has NKDA, no recent exposure to antibiotics, non-smoker. Would advise treatment of Amoxicillin 875 mg po BID for 7 days. Should start to note improvement in 2 – 3 days. Recheck in 10 – 14 days if symptoms have not completely cleared. Return sooner if signs of allergic reaction, fever, no improvement in 2 -3 days, or other new or worsening symptoms. Home adjunct treatments would include adequate fluids, sleeping upright, steamy showers or facial steam baths, nasal saline spray/washes.”

11. Common Mistakes in Oral Presentation a. Slow labored rhythm - a wandering, disorganized and desultory presentation is the most common problem encountered in early students. The ability to convert a written history and physical examination into a compressed presentation requires careful thought and practice. Ask your preceptor how long a presentation they would like. You should maintain eye contact with your listener during the presentation, which means that you should refer to notes and not read your write-up. In order to keep it under 5 minutes, you will need to PRACTICE with role play cases. This is helpful to do with a classmate who can give you feedback and then let you try again. It is also worth video-taping or at least recording yourself and listening to the play-back – then you can give yourself feedback. b. History of present illness too brief - 90% of correct diagnoses come from the history alone; do not sabotage your listener’s understanding of the case by omitting important information. The HPI portion of the oral presentation, as a general rule, should take 1/3 to 1/2 of the 40 presentation time. Common pitfalls include incomplete characterization of the major symptoms, omitting pertinent negatives or positive ROS questions, and omitting specific information about past history that relates to the present problem. c. Failure to use parallel reference points - in both write-ups and oral presentation, relate time in “hours/days/weeks prior to admission”. Avoid “at 2:00 in the morning of last Wednesday” or “on May 25th; instead, say “three hours prior to admission”, or “at 2:00 am, three days prior to admission”. d. Editorializing in the middle of the presentation - avoid comments like “do you even want to hear this?…” or “cardiac examination revealed a systolic murmur….well, I thought heard it, but the resident didn’t…so maybe it isn’t there….I don’t really know….” e. Use of negative statements instead of positive statements. Positive statements add color and accuracy to your presentation. “Chest Xray shows normal heart size” is better than “chest X-ray shows no cardiomegaly”. “In summary, this patient’s problem is acute dyspnea” is better than “the patient’s problem is rule-out pneumonia”. f. Repetition- vary your sentence structure. An overly repetitious presentation is monotonous for the listener. “On pulmonary exam, the lungs were normal…on cardiac exam, the heart sounds were…, on lymph node exam, there were no cervical nodes…etc” is difficult to listen to and unnecessary – your listener knows that S1 and S2 are part of the cardiac exam! Use brief descriptive sentences: “an S3 gallop was heard at the left lower sternal border.” g. Disorganization - this problem is a result of lack of rehearsal. Stopping at the end of the HPI to say “Oh, I can’t believe I forgot to tell you this” will kill a presentation. Or “…in summary, this patient…wait, I forgot to tell you the most important thing…” You need to be aware that this can happens even with careful preparation. The best advice when you forget something crucial to your presentation, is to work it in as soon as possible and don’t make a big deal about it. h. Physical findings presented without proper terminology - for example, “lymph node exam shows some small cervical nodes” is not as descriptive as “…there were three soft tender mobile nodes in the left anterior cervical chain which measure 1 x 1 x 2 cm each…” Commitment to accuracy will improve your physical examination skills. i. Diagnoses used instead of descriptions in the physical examination - diagnoses belong in the assessment, descriptions in the physical examination. For example, avoid “exam showed the murmur of mitral regurgitation” …instead say “a 2/6 holosystolic murmur was heard at the apex when radiated to the axilla”. Avoid “skin exam showed psoriatic lesions on the elbows…”: instead, say “there were several 2 cm. diameter round plaques with silver scale distributed on the extensor surface of the elbows…”

Remember to practice! Remain professional and formal, using the same format each time and you will become proficient in this essential skill!

41 Appendix F Typhon Guidelines

Typhon is a patient tracking system used to document patient encounters throughout clinical experiences. It will be used to track clinical competencies. It can be accessed at https://www.typhongroup.net/np/data/login.asp?facility. University of Mary’s facility number is 7201.

Each student will be provided a user name and password. An orientation is provided prior to the first major clinical experience course. There are student tutorials available for review once a student is logged in. The following are guidelines to follow when using the system. • Clinical schedules must be entered by the student into Typhon as soon as they are established AND NO LESS THAN ONE WEEK PRIOR TO START OF CLINICALS. Students may not start clinicals until their schedule is entered into the Typhon system and their Clinical Objectives have been submitted in Canvas for Faculty Approval. • It is required that all patient encounters be entered. Remember, you are building your database of experiences. You want for it to showcase the variety of conditions, diagnostics, pharmacological plans, and procedures that you have had exposure and experience with. The quality of what you put in impacts the quality of the product you will have at the end. It should be your goal to maximize this tool’s potential as a professional marketing portfolio for you in the future. • Clinical logs must be completed on a WEEKLY basis, however it is highly recommended that students enter encounters daily. All entries of patient encounters from the previous week must be entered in Typhon by Monday of each week! Should students become more than 1 week behind on Typhon entries, they will not be allowed to continue with the clinical experience until caught up. The Typhon system has a "lock" that only allows students to provide entries for a set number of days. If you are locked out from entering clinical data, the student will need to contact their clinical faculty for permission to enter their data and reschedule clinicals until they are caught up with previous encounters. The student will also need to contact their clinical preceptor with an update and reason for being unable to proceed with the clinical experience until further notice. This has become a facility requirement in many professional practices - when providers are more than a week behind on dictations, they are not allowed to see patients and required to take a personal day off to "catch up" on required documentation. Once the student is caught up, they will need to re-notify their faculty members and clinical preceptor to resume the clinical experience. • Student must enter clinical hours in the time log.

Typhon Patient Encounter Entry Requirements • Document your family practice, orthopedics, and mental health rotation patients. • All required fields must be completed • Pharmacologic management must be entered • Skills observed, assisted with or completed independently must be recorded on the skills checklist within typhon • CPT codes are required for procedures (splinting, I&D, laceration repair…) as well as diagnostics that were ordered (labs, x-rays, EKGs, CTs, ultrasounds…). • An E/M code is required to be entered for each patient encounter. • ICD-10 codes are required for all patient encounters. This is the diagnosis code. There may be more than one. • The notes section can be used to enter brief details of the encounter for purposes of recall and to help the faculty person reviewing the encounter understand the context of the visit and management plan.

42 • All Typhon entries must be approved by the student’s clinical faculty. Those left unapproved will need to be addressed by the students.

Typhon Entries Rubric

Criteria Criterion Fully Met Criterion Partially Met Criterion Not Met Timeliness Typhon entries for each Less than all Typhon No patient encounters week are submitted in entries are submitted by are entered. full by Monday for the Monday for patient 0.0 pts clinical encounters the encounters from the student has participated preceding week. in during the previous 3.0 pts week. 5.0 pts Entry Flow Each entry has sufficient Most entries have Entries include minimal information to sufficient information to information. demonstrate congruency demonstrate congruency 0.0 pts between the chief between the chief complaint, diagnostics, complaint, diagnostics, diagnosis, and diagnosis, and management plan. management plan. Students are encouraged Students are encouraged to include 1-2 sentence to include 1-2 sentence to enter brief details of to enter brief details of the encounter for the encounter for purposes of purposes of demonstrating critical demonstrating critical thinking or relationship thinking or relationship of encounter details to of encounter details to management plan. management plan. 5.0 pts 3.0 pts Pharmacologic Pharmacologic actions from patient encounters are Pharmacologic actions management included in each entry as appropriate. are missing on many 3.0 pts encounters that would have drug management. 0.0 pts Skills Each encounter that a skills was performed is noted Skills are not entered in in the skills list as either observed, assisted or Typhon. completed independently. 0.0 pts 2.0 pts Coding ICD-10, CPT, and E/M codes are entered for each Coding not done patient encounter. 0.0pts 5.0 pts

43 Examples of Primary Care Typhon Entries

44 Examples of Women’s Health Typhon Entries

Examples of ER/Urgent Care Typhon Entries

45 Appendix G Dictation Requirements Dictation Expectations The purpose for evaluation of dictations/documentations is to appraise your critical thinking skills as well as your proficiency in regard to assessment, diagnosis/impression, and development of a plan of care. In addition, assessments of clinical documentation assists with quantification of a student’s ability to formulate an accurate, clear, well organized record that reflects and facilitates sound clinical thinking. If you are not allowed to dictate, dictations must be self-typed and submitted. Dictations should reflect the criteria below and will be evaluated using the evaluation tool provided. For some courses, students may have to self-correct dictations and details will be outlined in individual clinical course syllabi. The required number of dictations required is outlined in course syllabi. Documentation criteria o Documentation is clear and well organized. o Appropriate medical terminology and anatomical descriptions are utilized. o No redundancy (repetitious words, phrases, and other distracting information are omitted). o Format follows a standard. Narratives such as the HPI and Exam have a logical flow. o HPI is fully developed and includes location, duration, timing, character, severity, provocative/palliative factors and/or other features appropriate for the reason for presentation. o Physical exam includes vital signs, height and weight for all children and for others as appropriate, and any relevant developmental data. o Appropriate diagnostic tests are performed/ordered. o Assessment and diagnosis reflect the patient’s symptoms and diagnostic tests o Clinical decision making is documented regarding diagnostics, differential diagnosis, treatment plan and follow-up. o Management plan is appropriate for the diagnosis and accurately addresses the problem identified. o Management plan is economically sound. o Management plan includes plans for evaluation/follow-up care (as appropriate). o Management plan is individualized to the patient’s age and development, culture, religion, family, environment, education, and/or any other unique concerns uncovered in assessment. o Level of visit and documentation consistent with E/M guidelines key components

Number of Dictations o The student must satisfactorily complete 8 Dictations/Documentations o 3 of the dictations need to be comprehensive H&Ps o 5 focused H&Ps o All dictations must represent a different presenting complaint or age category for the comprehensive exam o Demonstrate a variety of common health problems o All dictation must be self-corrected. For example when you receive your dictation back, review the protocol material for any missing questions, system examinations, management….etc. Make these corrections on the typed form. 46 o The dictation grading rubric will be used for evaluation of submitted dictations o You must demonstrate competency on your focused exam documentations. You will be allowed only TWO different repeats of your documentation if you receive an initial fail. o The following web sites may be of some help as you begin to provide E/M guideline based documentation (refer to resources supplied in NUR 567)

47 Comprehensive History and Physical Examination Rubric

Other Considerations when documentation is for a female patient.

HPI – First sentence should include age, parity, LMP and present problem (details about cc and other relevant information).

Menstrual History Menarche, duration, flow and cycle length of menses, IMB (intermenstrual bleeding), or contact bleeding, dysmenorrheal, PMS, climacteric

Gynecologic History Breast history – history of breast disease, breast feeding, the use of SBE (Self Breast Exam), last mammogram (if applicable); previous gyn surgery (can include surgical history), history of infertility, history of DES (diethylstilbestrol) use by patients mother, last pap smear - history of abnormal pap.

Contraceptive/ Sexual Current method/patients satisfaction with current method

History Past Methods, current sexual activity, number of partners, new partner in the last 3 months, condom use, history of sexual abuse.

PMH Include infectious diseases (gonorrhea, chlamydia, syphilis, herpes, genital warts, trichomonas, HIV, TB, rheumatic fever, hepatitis)

Social History Marital status, employment, age and health of children, social supports

ROS Concentrate of GY/GI; pertinent negatives may include, abnormal discharge, abnormal bleeding, dyspareunia, abdominal/pelvic pain, dysuria, hesitancy, urgency, incontinence, change in bowel habits, rectal bleeding. For post/perimenopausal woman – hot flashes/night sweats, vaginal dryness, abnormal bleeding, irritability, depression, mood changes.

PE: At a minimum: Vital Signs, Thyroid, Breasts, Lungs, Heart, Abdomen, Extremities, Pelvic Exam, External genitalia, vagina, cervix, uterus abdomen, recto-vaginal

Other Considerations when documentation is for a pediatric patient.

A number of factors distinguish the pediatric from the adult history and physical exam. Depending on the age of the patient, the primary historian may be the patient and/or another person, usually the parent. Developmental factors are commonly considered. The differential diagnosis of a condition may vary depending on the age of the patient. Health care maintenance (e.g., immunizations and safety issues) and social issues play a major role in emergent and routine care. Therefore, key items must be considered for inclusion within the documentation note including: informant, prenatal history, birth and neonatal history, feeding history, immunization history, developmental/behavioral history, HEADDSS for the adolescents. For the physical exam: be sure to include head circumference, growth curves, etc. for appropriate age levels along with appropriate developmental assessment.

Comprehensive Examination Rubric

Criterion Criterion Criterion Criterion Criterion Not Inadequately Fully Met Partially Met Met Met Chief Complaint: 5pts 3pts 2pts 0pts Patient initials, age, and CC present. No identifying data

History of Present Illness: 15pts 10pts 6pts 0pts

48 Thoroughly documents all pertinent history components for type of note; includes critical as well as supportive information. HPI is fully developed and includes location, duration, timing, character, severity provocative/palliative factors, pertinent positives and pertinent negatives when appropriate.

Past medical, family, and social history:

Thoroughly documents all history components for PMH, FH, SH are included. Allergies, prescribed and over the counter medicines currently 10pts 8pts 6pts 0pts being used are noted. Evidence of extensive chart review. Includes vocational history when appropriate, current living situation, tobacco/alcohol/drug history, & medical history of first degree relatives.

Review of Systems: 10pts 8pts 6pts 0pts Complete review of systems is included.

General Survey/Vital Signs: 5pts 3pts 2pts 0pts General survey includes complete set of vital signs, height and weight, BMI, and other relevant data.

Physical Examination: 15pts 10pts 6pts 0pts All systems assessed. Appropriate descriptors are used to articulate the physical findings.

Labs/Diagnostics:

Pertinent lab and diagnostic findings are included with provider interpretation of any abnormal labs. Includes all pertinent labs, or references what 10pts 8pts 6pts 0pts should have been obtained

Management Plan:

States/identifies all appropriate final diagnosis/problem list. Each problem is addressed, either separately or as a constellation of problems, and a differential diagnosis is provided for each problem or problem constellation. Use of tests is discussed for each major problem. A complete, reasonable plan for each problem is suggested. Shares constructs that led to decisions and diagnostic decision making related to management 15pts 10pts 6pts 0pts plan, disposition, consult, and/or follow up recommendations. Includes appropriate patient education/anticipatory guidance, health promotion, pharmacological and non-pharmacological measures, consult/referral, and follow-up recommendations. Demonstrates practice recommendations based on evidenced based practice.

Evaluation and Management Coding:

Evaluation and management coding is stratified into the appropriate level of complexity based on the nature and number of clinical problems, 5pts 3pts 2pts 0pts amount and complexity of the data reviewed during the encounter, and/or the risk of morbidity and mortality to the patient. When appropriate, accurate procedure codes included with supporting documentation within the dictation

Organization and Grammar:

Documentation is clear and well organized without spelling errors. Correct medical terminology is used. Redundant words, phrases, and other 10pts 8pts 6pts 0pts distracting information are omitted. Record has a logical flow.

49 Focused or Episodic History and Physical Examination Rubric

Other Considerations: Female GYN/OB Examination

HPI – First sentence should include age, parity, LMP and present problem (details about cc and other relevant information).

Menstrual History Menarche, duration, flow and cycle length of menses, IMB (intermenstrual bleeding), or contact bleeding, dysmenorrheal, PMS, climacteric

Gynecologic History Breast history – history of breast disease, breast feeding, the use of SBE (Self Breast Exam), last mammogram (if applicable); previous gyn surgery (can include surgical history), history of infertility, history of DES (diethylstilbestrol) use by patients mother, last pap smear - history of abnormal pap.

Contraceptive/ Sexual Current method/patients satisfaction with current method

History Past Methods, current sexual activity, number of partners, new partner in the last 3 months, condom use, history of sexual abuse.

PMH Include infectious diseases (gonorrhea, chlamydia, syphilis, herpes, genital warts, trichomonas, HIV, TB, rheumatic fever, hepatitis)

Social History Marital status, employment, age and health of children, social supports

ROS Concentrate on GYN/GU/GI; pertinent negatives may include, abnormal discharge, abnormal bleeding, dyspareunia, abdominal/pelvic pain, dysuria, hesitancy, urgency, incontinence, change in bowel habits, rectal bleeding. For post/perimenopausal woman – hot flashes/night sweats, vaginal dryness, abnormal bleeding, irritability, depression, mood changes.

PE: At a minimum: Vital Signs, Thyroid, Breasts, Lungs, Heart, Abdomen, Extremities, Pelvic Exam, External genitalia, vagina, cervix, uterus abdomen, recto-vaginal

Other Considerations: Pediatric Examination

A number of factors distinguish the pediatric from the adult history and physical exam. Depending on the age of the patient, the primary historian may be the patient and/or another person, usually the parent. Developmental factors are commonly considered. The differential diagnosis of a condition may vary depending on the age of the patient. Health care maintenance (e.g., immunizations and safety issues) and social issues play a major role in emergent and routine care. Therefore, key items must be considered for inclusion within the documentation note including: informant, prenatal history, birth and neonatal history, feeding history, immunization history, developmental/behavioral history, HEADDSS for the adolescents. For the physical exam: be sure to include head circumference, growth curves, etc. for appropriate age levels along with appropriate developmental assessment.

Focused Problem Rubric

Criterion Criterion Criterion Criterion Criterion Not Inadequately Fully Met Partially Met Met Met Chief Complaint: 5pts 3pts 2pts 0pts Targeted CC present without the inclusion of extraneous information. Patient initials and age present without identifying data.

History of Present Illness:

HPI is targeted toward the reason for presentation without the inclusion of extraneous information. HPI is fully developed and includes location, 15pts 10pts 6pts 0pts duration, timing, character, severity provocative/palliative factors, pertinent positives and pertinent negatives.

50 Focused Problem Rubric

Past medical, family, and social history:

Elements of the PMH that expand on the CC and HPI are included, yet irrelevant information is excluded. Elements of the FH and SH that 10pts 8pts 6pts 0pts expand on the CC and HPI are included, yet irrelevant information is excluded.

Review of Systems: 10pts 8pts 6pts 0pts Elements of the ROS that expand on the CC and HPI are included, yet irrelevant information is excluded

General Survey/Vital Signs: 5pts 3pts 2pts 0pts General survey includes vital signs, height and weight, BMI, and other relevant data related to CC.

Physical Examination: 15pts 10pts 6pts 0pts All systems assessed focus on the CC. Appropriate descriptors are used to articulate the physical findings.

Labs/Diagnostics: 10pts 8pts 6pts 0pts Pertinent lab and diagnostic findings are included along with appropriate comments regarding abnormal labs and inclusion of pertinent positives.

Management Plan:

States/identifies appropriate final diagnosis. Shares constructs that led to decisions and diagnostic decision making related to management plan, disposition, consult, and/or follow up recommendations. Includes appropriate patient education/anticipatory guidance, health promotion, 15pts 10pts 6pts 0pts pharmacological and non-pharmacological measures, consult/referral, and follow-up recommendations. Demonstrates practice recommendations based on evidenced based practice.

Evaluation and Management Coding:

Evaluation and management coding is stratified into the appropriate level of complexity based on the nature and number of clinical problems, 5pts 3pts 2pts 0pts amount and complexity of the data reviewed during the encounter, and/or the risk of morbidity and mortality to the patient. When appropriate, accurate procedure codes included with supporting documentation within the dictation.

Organization and Grammar:

Documentation is clear and well organized without spelling errors. Correct medical terminology is used. Redundant words, phrases, and other 10pts 8pts 6pts 0pts distracting information are omitted. Record has a logical flow.

51 DICTATION EXAMPLE USED WITH PERMISSION

Date of Service: 06/29/18 Initials: R. W. MRN: XXXXXXX

General Patient Information: Age: 29 years Sex: Female Race: Caucasian

Primary historian: Patient, Patient’s mother

Chief complaint: Nausea, dizzy, overheated

History of Present Illness: R.W. is an otherwise healthy 29-year-old female who presents to the emergency room by private vehicle with complaints of nausea, fatigue, and feeling overheated. Reports that she was out in the boat for about two hours this afternoon in 90-degree weather. States she began feeling ill and fatigued while on the boat, and lay down for a rest once returning home. She woke up feeling nauseated, which was unrelieved with ODT Zofran and lying in an air-conditioned environment. She has had at least one episode of emesis. Reports associated dizziness, lightheadedness, malaise, weakness, headache, muscle/abdominal cramping, and heart palpitations. She states she drank one bottle of water today. Denies any previous history of heat exhaustion or heat stroke, but states she is “sensitive” to the sun and does not feel well when in a warm environment for prolonged periods. Denies feeling ill prior to this experience.

Past Medical History - Cervical Cancer (2016) - Renal calculi

Surgical History - Septoplasty (2018) - Adenoidectomy (2018)

Family History - Noncontributory.

Social History R. W. lives with her family. States that she is not worried about recurrent heat symptoms and has no sun exposure at her work. She is on vacation for a week, and has been spending time on the water for the past few days. Reports that she does not drink much water normally.

Medications - Albuterol 8 gm IH as directed PRN - Spironolactone 25 mg PO bedtime - Norethindrone-Ethinyl Estrad 1 each PO daily - Fluoxetine HCl 20 mg PO daily - Metformin 1,000 mg PO daily - Bupropion HCl 150 mg PO daily

Allergies - Penicillins – Nausea and vomiting

Review of Systems: 52 General: Denies fever or chills. Reports malaise and fatigue. Head: Reports headaches and a history of migraines. No trauma. Eyes: Denies visual changes, visual loss, blurring, or double vision. Gastrointestinal: Reports nausea, vomiting, and abdominal pain. Denies appetite changes or diarrhea. Respiratory: Denies shortness of breath. Cardiac/Peripheral vascular: Reports a brief period of palpitations which have since resolved. No chest pain or peripheral edema. Musculoskeletal: Reports muscle weakness and generalized muscle cramping. Genitourinary: No dysuria, hematuria, or other urinary symptoms. Integumentary: Reports rash over arms and upper chest. Neurologic: Denies seizures or changes in level of consciousness.

Physical examination: Vital Signs: Heart rate 88, Temperature 36.8 C tympanic, Respiratory rate 17, Oxygen saturations 97% on room air, BP 154/97, Height 1.57 m, Weight 85.275 kg, BMI 34.4 kg/m2 General appearance: This is a pleasant female in no acute distress who appears her stated age. She appears pale and fatigued, but is conversant and answers questions appropriately. Eyes: Sclera nonicteric. Pupils are equal, round, and 2mm in size. EOMs intact, with horizontal nystagmus noted. Pharynx: Mucous membranes moist. Cardiac/Peripheral vascular: Heart rate is tachycardic with regular rhythm. No murmurs, gallops, clicks, or splitting. No peripheral edema. Gastrointestinal: Abdomen rounded, with no evident pulsations. Bowel sounds active x4 quadrants. Abdomen soft to palpation and tender in the upper quadrants. No guarding or rigidity. Respiratory: Respirations easy, even, and unlabored. No cyanosis. Lung sounds clear to auscultation, equal bilaterally, and free of adventitious sounds. No cough noted. Integumentary: Scattered maculopapular rash noted over upper chest and arms bilaterally. No evidence of sweating or diaphoresis. Musculoskeletal: No tremors. Demonstrates no functional deficits. Strength equal in upper extremities. Gait unobserved. Neurologic: The patient is alert and oriented x4. Speech is clear. No confusion noted. Cranial nerves II-XII grossly intact.

Labs/Diagnostics 1. CBC with differential - WBC 9.9 - RBC 4.18 - HGB 13.1 - HCT 39.8 - MCV 95 - MCH 31 - MCHC 33 - Plt Count 380 - Neutrophils 70 - Lymphocytes 21 - Monocytes 7 - Eosinophils 1 - Basophils 0 2. BMP - Sodium 140 - Potassium 4.2 - Chloride 106 - Carbon Dioxide 27 - Anion Gap 7.5 53 - BUN 10 - Creatinine 1.0 - Est Cr Clr Drug Dosing 65.65 - Estimated GFR (MDRD) >60 - Glucose 93 - Calcium 9.5 3. Magnesium 2.0 4. Urinalysis - Urine Color Yellow - Urine Appearance Cloudy - Urine pH 5.0 - Ur Specific Gravity 1.025 - Urine Protein Negative - Urine Glucose Normal - Urine Ketones Negative - Urine Occult Blood Large - Urine Nitrite Negative - Urine Bilirubin Small - Urine Urobilinogen Normal - Ur Leukocyte Esterase Negative - Urine RBC 10-20 – Reports she is spotting with her period. - Urine WBC 0-5 - Ur Epithelial Cells Moderate - Amorphous Sediment Few - Urine Bacteria Few - Urine Mucus Few

Assessment 1. Heat exhaustion, unspecified – ICD 10 T67.5

Differential Diagnoses Differential diagnoses for heat exhaustion are as follows: 1. Migraine headache – The patient’s nausea, vomiting, and frontal headache suggest possible migraine headache, which is congruent with the patient’s history. However, she states that this does not feel like a typical migraine for her, and its association with other symptoms of heat exhaustion support that as the primary diagnosis. 2. Heat stroke – The patient’s history of feeling overheated, along with her numerous somatic complaints and lack of hydration make this a possibility. However, her lack of neurological symptoms, such as seizures and decreased level of consciousness, reduce this possibility. Additionally, her normal temperature on exam supports heat exhaustion as the primary diagnosis. Plan 1. Heat exhaustion – The patient’s sudden onset of symptoms after spending time in the heat supports this diagnosis. Her laboratory studies were unremarkable. - The patient refused IV hydration and anti-nausea medications here. She was given 1 dose of ODT Zofran and reported that her symptoms resolved following this medication (with the exception of a mild frontal headache). - Zofran script provided for ongoing nausea. - Pt should drink a minimum of 8-10 glasses of water daily and increase water intake when in the heat. - Avoid strenuous activities in hot weather. Wear cool, breathable clothing to reduce excess heat exposure. - Take cool showers or baths as needed to reduce the symptoms of heat rash. - Discussed the need to be cautious with heat exposure in the future, as the patient will likely be prone to recurrences. - Seek immediate care if experiencing seizures, difficulty breathing, ongoing nausea and vomiting, or any other concerning symptoms. 54 Total Time Spent: 25 minutes Signed: Jenise Ropp, RN, FNP-s E/M CPT Codes: #1 - 85025 - BLOOD COUNT; COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, & PLATELET) & AUTOMATED DIFFERENTIAL WBC #2 - 81015 - URINALYSIS; MICROSCOPIC ONLY #3 - 80048 - BASIC METABOLIC PANEL (CALCIUM, TOTAL) #4 - 83735 - MAGNESIUM #5 - 99281 - EMERGENCY DEPT VISIT, 3 KEY COMPONENTS: PROB FOCUS HX; PROB FOCUS EXAM; STRTFWD MED DECISION 1. History a. HPI – Extended b. ROS – Extended c. PFSH – Pertinent d. History – Detailed 2. Exam – Detailed 3. MDM a. Number of Diagnoses – 1 (Self-limited or minor) b. Complexity of data reviewed: 1 (review or order clinical lab tests) c. Risk: Minimal (One self-limited or minor problem) 4. Overall MDM – Straightforward Complexity

55 Appendix H Clinical Site Visit Tool

Clinical Site Visit Guide "Mid-Term FACULTY Evaluation of CLINICAL SITE, PRECEPTOR, and STUDENT"

OVERALL SUMMARY:

The degree to which the FACULTY determines the CLINICAL EXPERIENCE to:

1. Facilitate the students’ ability to engage in learning activities that contribute to the growth and development related to course, clinical, and/or personal objectives established for the precepted experience.

Strongly Strongly Agree Agree Disagree Disagree

2. Promote student integration of new knowledge and attainment of program outcomes.

Strongly Strongly Agree Agree Disagree Disagree

3. Foster interprofessional collaborative practices.

Strongly Strongly Agree Agree Disagree Disagree

56

4. Meet the identified academic and/or experiential qualifications required of a preceptor.

Strongly Strongly Agree Agree Disagree Disagree

5 What type of clinical site visit was performed? Onsite Visit, Primary preceptor and student present Onsite Visit, Secondary preceptor and student present Phone Visit with Preceptor Additional Comments:

6 Name of Preceptor and Phone Number

Enter a response

7 Site Name and Address

Enter a response

57 8 Primary Practice Type

Adult Health (Ages 19 - 99+) Family Practice (All ages) Pediatrics (Ages 18 and below) Women's Health OB ER Hospitalist Specialist OTHER - Note in text box below. Additional Comments:

9 QUESTIONS FOR PRECEPTOR and/or STUDENT:

Has the student reviewed their clinical objectives with you?

What is the average number of patients per clinical day the student is exposed to?

What types of patients are being seen/evaluated by the student?

Can you describe a typical day with the student?

Enter a response

10 QUESTION FOR PRECEPTOR - Interviewing and History Taking

What PROMOTES or NEGATES YOUR CONFIDENCE for the student to have independence with seeing and then presenting a case to you?

Explain your assessment of the student's approach to establishing rapport, identifying a chief complaint and collecting a history.

58 Enter a response

11 QUESTION FOR PRECEPTOR - Physical Exam

What parts of the physical exam do you feel the student needs more experience in or can you given me an example of an occasion the student did remarkably well during their physical exam?

Can you please comment on degree of competence the student has displayed with any psychomotor skills (i.e. procedures/specialty exams) you’ve observed during the student’s rotation?

Enter a response

12 QUESTION FOR PRECEPTOR - Documentation

How would you rate the student’s use of medical terminology and encounter documentation?

If not able to document, can the student scribe for you?

Enter a response

13 QUESTION FOR PRECEPTOR - Critical Thinking/Application of Knowledge - Management Planning

Are there examples of the student’s performance in critical thinking, appropriate decision making, and diagnostic test interpretation that you can share with me?

Can you describe an example of how the student has or has not grown in ability to formulate a management plan, engage in consultation/referral, and provide patient education?

Enter a response 59 14 QUESTION FOR PRECEPTOR - Professionalism

Can you share examples that indicate the student’s degree of professionalism throughout the rotation (for example, mannerisms, attire, timeliness, communication with patients/staff)?

Enter a response

15 QUESTION FOR PRECEPTOR - Opportunities/Strengths

During the time you had with our student can you provide areas of opportunities for improvement that I could share with the student?

Can you share strengths regarding the student exhibited during their rotation?

Enter a response

16 QUESTION FOR PRECEPTOR - University Relationship

Is there anything the University of Mary can improve on for facilitating/improving the university/student/preceptor relationship and interactions?

Enter a response

60 Questions for Faculty Observation of Clinical Site

YES NO NA

17 Preceptor makes time for student to review chart and plan care with preceptor before patient encounter, as appropriate for student’s developmental level.

Additional Comments

18 Preceptor makes time for student to review visit and plan of care after encounter.

Additional Comments

19 Preceptor provides opportunities for student to learn how to consult appropriately.

Additional Comments

61 20 Expectations for student performance are consistent with accepted professional competencies for safe beginning-level practitioner.

Additional Comments

21 Preceptor requires problem-focused documentation of patient care that is accurate and complete.

Additional Comments

YES NO NA

22 Preceptor provides opportunities for students to learn prescribing, triage, evaluation, development of interprofessional relationships, and follow-up of laboratory results.

Additional Comments

62 23 A preceptor reviews and signs all student documentation of care.

Additional Comments

24 The preceptor demonstrates a philosophy that fosters holistic care as demonstrated by the practice philosophy statement, charting, or observed patient care.

Additional Comments

25 The practice site can be accessed safely by the student.

Additional Comments

26 The site has adequate space for students to work, study, and rest (e.g., dictation, access computer desk space).

63 Additional Comments

YES NO NA

27 Clinic staff welcomes student/faculty. Pleasant and friendly environment.

YES NO NA

Additional Comments

28

FACULTY observation of STUDENT with CLINICAL PATIENT:

Please provide a brief description of the patient case encounter observed.

29 EVALUATION OF STUDENT WITH CLINICAL PATIENT

RATING SCALE

1 - NOVICE

64 Knows the general rules to help perform tasks; relies on guidelines/standards on which to base treatment/management, rather than on previous past experience. Student: Requires guidance to determine which guidelines/standards to choose; beginning to develop differentials, recognize some normal versus abnormal conditions.

2 - ADVANCED BEGINNER

Has had some prior experience with which to frame judgments and formulate management plans; requires supportive cues but less so than beginner stage. Student: Increasingly independent in their ability to develop a differential list and use guidelines/standards to formulate a management plan; increasingly recognizes normal versus abnormal conditions.

3 - COMPETENT

More past experiences upon which to base their clinical reasoning and judgement; developing the ability to prioritize care and formulate management plans; gaining efficiency in clinical practice. Student: Increasingly independent in their ability to develop a differential list and use guidelines/standards to formulate a management plan; increasingly recognizes normal versus abnormal conditions (in specific populations); starting to recognize the need for consultation and referral.

4 - PROFICIENT

Able to anticipate patient course from previous experience; ability to prioritize care and formulate management plans based on previous experience; efficient clinical practice; developing intuition. Student: Independent in their ability to develop a differential list and use guidelines/standards to formulate a management plan; recognizes normal versus abnormal conditions in most populations; recognizes the need for consultation and referral.

5 - EXPERT

Confident; solid knowledge base on which to formulate judgements and develop management plans; intuitive ability to quickly read patient situations. Student: exceptional in their ability to perform independently; intuitive grasp of patient situations; recognizes the need for consultation and referral.

ADVANCED NOVICE BEGINNER COMPETENT PROFICIENT EXPERT

65 HISTORY COLLECTION: Employs skillful interviewing techniques to identify pertinent positive and pertinent negative historical data in the adult patient population. Gathers relevant historical health data for patients of all ages.

Additional Comments

HISTORY COLLECTION: Distinguishes between relevant and irrelevant subjective data.

66 ADVANCED NOVICE BEGINNER COMPETENT PROFICIENT EXPERT

Additional Comments

PHYSICAL EXAMINATION: Performs an indicated timely and organized physical exam to differentiate normal from abnormal to identify obvious and subtle findings. Differentiate normal from abnormal findings, and/or change across the lifespan.

Additional Comments

67 PHYSICAL EXAMINATION: Identifies obvious and subtle findings of significance.

Additional Comments

PHYSICAL EXAMINATION: Modifies the physical exam with regard to the chief complaint and history of present illness.

Additional Comments

NOVICE ADVANCED COMPETENT PROFICIENT EXPERT BEGINNER

68 DIAGNOSIS: Formulates appropriate differential diagnoses based on client data.

Additional Comments

ADVANCED NOVICE BEGINNER COMPETENT PROFICIENT EXPERT

DIAGNOSIS: Selects appropriate diagnostic modalities necessary for evaluation of client condition.

Additional Comments

69 DIAGNOSIS: Selects and conduct appropriate screening procedures as deemed appropriate.

Additional Comments

MANAGEMENT: Initiates nursing and medical interventions to promote health, treat health alterations, and to prevent illness using evidencebased resources.

Additional Comments

70 MANAGEMENT: Recognizes indications for pharmaceutical management.

Additional Comments

NOVICE ADVANCED COMPETENT PROFICIENT EXPERT BEGINNER

MANAGEMENT: Calculates and prescribes appropriate medication doses based on client characteristics (age, weight, etc.)

ADVANCED NOVICE BEGINNER COMPETENT PROFICIENT EXPERT

Additional Comments

71 MANAGEMENT: Performs procedures as indicated.

Additional Comments

TEACHING: Assesses client readiness to learn.

Additional Comments

TEACHING: Informs clients at an educational level best suited for their optimal understanding.

Additional Comments

TEACHING: Aware of a variety of resources for

72 counseling and referral.

Additional Comments

NOVICE ADVANCED COMPETENT PROFICIENT EXPERT BEGINNER

COMMUNICATION: Gives a brief, succinct case presentation with appropriate terminology in an organized manner.

Additional Comments

ADVANCED NOVICE BEGINNER COMPETENT PROFICIENT EXPERT

73 COMMUNICATION: Accurately documents history and physical in the client’s medical record succinctly and systematically.

Additional Comments

COMMUNICATION: Informs the client of their health status including diagnosis, management, therapeutics, consultations, and referrals.

Additional Comments

74 LEADERSHIP and ROLE INTEGRATION: The student is punctual, has a professional appearance in all clinical experiences, displays initiative, and possesses interpersonal skills that promote effective interactions with healthcare team members and patients

Additional Comments

30 Please provide any additional comments or concerns for the clinical site visit.

Enter a response

75 Appendix I Choosing the Correct Outpatient E/M Coding

76

77 Appendix J Hotseat Competency Pearls

Student clinical competence is further evaluated by faculty during practical testing that occurs on campus at the conclusion of each clinical course. Using a simulated scenario the student is evaluated on their history, physical exam, clinical decision making, diagnosis, management, and patient education competence. This competency testing is coined “hot seat” because they are evaluated in real time by faculty while also being observed by their peers.

This is a PASS/FAIL requirement. If a student fails the Hotseat Competency, several other factors are taken into consideration. Based on an overall assessment of the student’s performance in the clinical setting and FNP course work, students may be required to repeat the course, repeat another Hotseat Competency, complete additional clinical hours, or work one on one with faculty followed by another Hotseat Competency. The final recommendation will be made based on feedback from at least two clinical faculty. • Each student will be assigned a case pertinent to the clinical course most recently completed. Primary Care Clinical Experience will include cases that commonly present to an outpatient family practice clinic. Acute and Emergent Cases will be presented to students after completing their Acute and Emergent Clinical. • One instructor will be the patient and another instructor will be the Examiner. Both will assist in evaluating student competence. • The expectation is for the student to present to the patient just like you would in that clinical setting. • The student will conduct a focused history and physical exam just as you would in that clinical setting. If it is a complaint that requires a more comprehensive evaluation such as a preventive exam, you will modify your questions and exam to meet that criteria. • Each student will only have 15 - 20 minutes for your history and exam. • Please bring any assessment tools (stethoscope, etc) or references (procedure books, EKG manual, ACLS or TNCC algorithms, etc) that you want readily available. • Dress professionally. • When conducting the exam, the student is to assume their findings are normal unless the instructor states something is abnormal - for example: as you are listening to the heart - (the instructor might state "you hear a grade 3/6 systolic murmur") - if nothing is said - assume it is a normal exam. If you are assessing a sprained ankle - ("you see moderate swelling with bruising to the heel area, but no deformity, no bony tenderness, pain moderate over anterior talofibular ligament" - this is what you will note in your exam findings. If you are concerned the "Examiner" will not realize what you are assessing - tell your patient - "I'm listening to your heart now". "I'm checking your abdomen for any tenderness or abnormalities." etc... • During the exam portion be sure you are conducting your exam appropriately. For example, listening to the correct locations over the carotid and instructing the patient to hold their breath for a few seconds. Listening to the correct locations of the heart. If you are observed listening to just two areas of the back and two areas on the front chest – this is an obvious fail. • If you have an orthopedic complaint - you are expected to complete a true hands on focused musculoskeletal exam. • The only exception would be to verbalize breast, rectal, and GU exams. • After completing the exam - you will need to direct any planning and recommendations to the "patient" in regard to your findings along with any recommendations or plans for further evaluation, including labs and diagnostics. If no further testing, you will make an excuse to step away from the patient to order your diagnostics or review studies completed and put together a discharge plan. We 78 are also assessing your ability to communicate fully with the patient, conduct appropriate exams, and transition from history/exam/and discharge. You can complete your history along with your examination. • After you "step away" from the patient, the Examiner will hand you your requested test results (the tests you told the patient you would be ordering), give you a verbal report, or show you x-rays if available through the computer for review. If a procedure is required such as suturing, you will be provided the materials to perform. • You can then do a brief check in with their peers - "did I miss anything?" "my initial plan is this... am I on target?". This step gives you a "safety net" and "consult" - which I would hope and assume you will probably do to start out in your new career; and gives the other students a chance to be involved in multiple cases. Listening students – HELP your colleagues!!! Like in the real world we tend to be so caught up with our own patients – we don’t always “listen” and or provide the best direction. Thus – it is an art to know when your consultants are truly hearing you and which ones provide the best recommendations. • For a couple of the cases - an outside consult may be needed - then the Examining Instructor would be the consultant. Otherwise - you will have little interaction with the Examiner. If you need to call a specialist, DO!! • The testing student will then finish reviewing diagnostics and writing out a final discharge plan, prescriptions, admit or transfer orders, etc. while another student will begin - then swap again to close off with your patient. • Like an actual patient you will need to decide to treat and discharge home, or if needed admit, or transfer your patients. If admitting or transferring, you will need to note type of acuity, transfer needs, and provide a report to your accepting provider. Be prepared with what you need to communicate for the safety of your patient. • The student will complete a documentation note following the Hotseat. Documentation templates will be available for the student to use. However, if you have a template you prefer to use or feel more comfortable writing out on your own – that is acceptable as well. Be sure to accurately document any procedures performed. • As a reminder - only document what you completed or observed and remain focused to your specific case. If you are asked to complete a "physical" - obviously you will gather more material. If it is a focused complaint - will want to focus on items specific for your case. At the end of the Hotseat Experience, all documentation will be collected and used for assessing competency. • Some cases are quite short - others a little longer depending on the clinical setting. • There are some cases that have x-rays, EKG’s, available in the Canvas Hot Seat Sandbox; and some cases that have pictures or videos. • There will be a brief closing debriefing, then can still complete/finish your "dictation" or documentation template while the other students are completing their hot seats. We will collect the dictations at the end of the experience. A final debriefing will be completed via GOTOMEETING within the month following Hotseat examinations. • An example of a Hotseat Case and Evaluation Form is provided for your review. • You got this!! Do your best to have fun and show your stuff!

79 HOTSEAT CASE EXAMPLE NUR690 Case 6: Thomas Underwood STUDENT INFORMATION NAME: Thomas Underwood AGE: 58-year-old African American Male CHIEF COMPLAINT: “Having to get up a lot at night to urinate” MEDICATIONS: Diphenhydramine 50 mg po HS. ALLERGIES: NKDA VITAL SIGNS: Height: 5’10” Weight: 175# BMI: 25.1 Pulse: 88 bpm and regular; Respirations: 16 per minute Temperature: 97.9 F Blood Pressures: 130/72

80 Thomas Underwood

Presenting Complaint: “Having to get up a lot at night to urinate”

Final Diagnosis: Benign Prostatic Hypertrophy, Symptoms worsened by antihistamine use

Patient Demographics: Age: 58 years old Gender: Male; African American

Case Objectives: • Obtain a through history and physical examination based on the presenting complaint. • Develop a comprehensive list of differential diagnosis. • Identify appropriate diagnostic studies, consultations, if indicated, to further clarify definitive diagnosis. • Note final diagnosis. • Provide patient education plan with necessary written instructions, transfer, referral, or admission. • Complete a written documentation note. Case Setting: Clinic

81

Chief Complaint: “Having to get up a lot at night to urinate.” History of Present Illness: Mr. Underwood is a 58-year-old African American male who presents with the chief complaint of “having to get up a lot at night to urinate.” The nocturia began approximately 2 years ago and consisted of having to get up once at night to urinate; however, for the past month this has increased to three to four times per night. It interferes with the quality and quantity of his sleep, leaving him drowsy at work the following day. In addition, he is experiencing urinary urgency, urgency frequency, sensation of incomplete bladder emptying after voiding, difficulty starting stream, straining to continue stream, weaker force and diameter of the stream, and postvoid dribbling. He has not noticed an abnormal or unusual odor to his urine. He is not having any abdominal pain, back pain, flank pain, fever, nausea, vomiting, urinary incontinence, urethral discharge, bowel changes, leg weakness, or paresthesias affecting the trunk or lower extremities. Past Medical History: Mild Seasonal Allergic Rhinitis – Currently Controlled with diphenhydramine started 1 month ago. No previous hospitalizations. Has NOT had age appropriate immunizations or screening evaluations. Past Surgical History: None Past Family History: Unremarkable – negative for prostate or bladder cancer. MEDICATIONS: Diphenhydramine 50 mg PO HS for the last month. No other OTC, Herbal, or Vitamins. ALLERGIES: NKDA SOCIAL HISTORY: Smoker 1 ppd for last 40 years. Drinks alcohol on occasion (two drinks every 2 to 3 months). Married. Children are grown and out of the house. Business manager for a construction company. Last Visit to Health Care Provider: Over 8 years ago. REVIEW OF SYSTEMS: General: Denies recent anorexia, weight loss, night sweats, true fatigue. Genitourinary: Denies gross hematuria. Denies erectile dysfunction. Sleep History: Normally goes to bed at 10 pm and watches television until midnight. Does not consume beverages during this time period. Does admit in last month has increased caffeinated beverage intake to 5 to 10 drinks during work hours to “stay awake and alert.”

82 All other ROS negative. PHYSICAL EXAM:

Vital Signs: Height: 5’10” Weight: 175# BMI: 25.1 Pulse: 88 bpm and regular; Respirations: 16 per minute Temperature: 97.9 F Blood Pressures: 130/72 General: Alert and oriented. No acute distress. Appears well. CVS: Regular rate and rhythm, without murmurs, gallops, or rubs. Apical impulse is nondisplaced and without any thrills. Respiratory: Lung fields are clear and equal bilaterally. Abdomen: Active bowel sounds in all four quadrants. Soft, non-tender. No masses or organomegaly. Rectal examination is normal except for a slightly enlarged, smooth prostate with a shallow medial furrow. Normal in consistency and does not reveal any masses or indentations. Genitourinary: Both testicles are descended and without masses; scrotal sacs are nontender and without abnormal masses; midline urethra; and status postcircumcision. No lesions, lymphadenopathy, or hernias are identified. Skin: Warm and dry without rash. No new lesions. No edema to lower extremities DIAGNOSTIC TESTING: Post Void Residual Urine (PVR): 155 mL (normal: <100-200) PSA: 4.5 ng/ml (normal: <4) UA: Unremarkable Serum Creatinine: 0.8 mg/dl (normal male: 0.6 – 1.2) FINAL DIAGNOSIS: 1. Benign Prostatic Hypertrophy – Symptoms worsened by antihistamine usage (In view of negative findings with additional history questions, physical exam, and diagnostic results, most likely diagnosis.

PLAN: 1. Medications:

• Stop diphenhydramine and try topical cromolyn sodium for allergic rhinitis. Symptoms of BPH can be worsened by patients taking antihistamines. Other medications that exacerbate BPH symptoms include anticholinergics, decongestants, tranquilizers, and alpha-adrenergic agonists. • Start Tamsulosin 0.4 mg 30 minutes before bed: can increase to 0.8 mg if patient tolerates and continues to be symptomatic. Tamsulosin, as well as any other alpha-blocker, is an appropriate first- line agent to treat BPH. If maximum dosage does not produce the desired results (or is not tolerated by the patient), then the addition of a 5alpha-reductase inhibitor, which is generally considered a second- line agent, should be considered. However, it would not be totally incorrect to begin a patient with severe symptoms on both. If this combination fails, a urology consult is indicated for additional

83 evaluation, confirmation of diagnosis, the addition of an anticholinergic agent, and/or surgical intervention. 2. Decrease if possible eliminate caffeine, and avoid fluids 4 to 6 hours before bedtime. Caffeine can increase urinary frequency because it is both a bladder irritant and a diuretic. This urinary frequency can occur both during the day and at night; hence, eliminating caffeine from his diet is likely to reduce the frequency of nocturia. Eliminating fluids (especially caffeine and alcohol) 4 to 6 hours before bedtime will make less urine during the night and hopefully reduce frequency of nocturia.

3. Schedule for a Prostatic Ultrasound. The PSA level is slightly elevated; however, considering current symptoms and DRE findings, it is most likely caused by BPH. However, because the PSA is slightly elevated, it could represent an early prostate carcinoma in addition to the BPH. Risk factors for prostate cancer include tobacco use, African American descent, age, and current symptoms of change. 7. Final recommendations pending ultrasound. Consider Urology consult if Ultrasound is of concern and or no improvement in symptoms in 4 – 6 weeks. Return to clinic in 4 weeks for recheck of symptoms. Sooner if new or worsening concerns.

84 NUR690 Case 6: Thomas Underwood HOT SEAT Competency Rubric

Evaluation Criteria Rating Scale Comments Communication 1. Establishes rapport 1 2 3 4 5 NA 2. Interviews patient with confidence 1 2 3 4 5 NA 3. Identifies patient’s chief complaint and 1 2 3 4 5 NA patient concerns • Determines what the client thinks may be diagnosis or cause of problem 4. Preserves alertness to patient clues 1 2 3 4 5 NA 5. Maintains control in difficult patient 1 2 3 4 5 NA encounters 6. Shows use of pre-encounter dates from 1 2 3 4 5 NA patient or nurse’s comments/notes Knowledge 1. Conducts history in a manner that 1 2 3 4 5 NA ESSENTIAL: assists provider to narrow differential • Elicit recent history of anorexia, weight loss, night sweats, or true fatigue. Constitutional • Timing/onset/duration/frequency • Onset of nocturia 2 • Location/radiation symptoms could indicate the presence of an years ago – with once a associated malignancy including prostate or • Character or quality night. bladder cancer. • Quantity/severity • Much worse the last • Any gross hematuria? Can be associated with • Associating factors month – coincided with nephrolithiasis, bladder cancer, or urinary • Aggravating factors start of nightly tract infection. Regardless of symptoms, diphenhydramine, now • Alleviating factors patients with painless hematuria in 3 – 4 times a noc. • Past medical history conjunction with risk factors for bladder • Interferes with quality cancer are considered to have bladder cancer • Family medical history and quantity of sleep. until proven otherwise. Bladder cancer risk • Personal and social history Drowsy at work. factors include male gender, Caucasian race, • Current medications • Experiencing urinary advancing age, cigarette smoking, aniline dye • Allergies urgency, urgency (found in fabric dye, hair coloring, and wood • Review of systems frequency, sensation of stains) exposure, some medications incomplete bladder (phenacetin and chloranaphazine), and emptying after voiding, previous radiation therapy especially an difficulty starting external beam. stream, starting to • Does he have any problems with erectile continue stream, dysfunction? Because his symptoms could be weaker force and caused by prostatic tissue hypertrophy and diameter of stream, the currently accepted theory is that prostate and post void residual. gland enlargement, which is associated with • Denies unusual or the normal aging process, results from abnormal urine odor. decreasing testosterone levels (which also • Denies abdominal pain, occur with the normal aging process), it is back pain, flank pain, important to determine whether the patient is fever, nausea, vomiting, experiencing symptoms suggestive of a urinary incontinence, decreased testosterone state. One of the urethral discharge, primary symptoms caused by bowel changes, leg hypotestosteronism is ED. weakness, or • How much caffeine does he consume in the paresthesias affecting average day? Caffeine is considered to be a the trunk or lower bladder irritant and diuretic. Excessive extremities. caffeine intake can increase urinary output • Family history negative and frequency of voiding, including at night. for bladder, prostate, Non-Essential or other cancers. 85 • Smoker 40 pack year • What is his bedtime routine? Routine night routines usually will not have an effect on voiding unless involves fluid intake. Bedtime routines do have an effect on overall sleep efficiency. 2. Shows evidence of critical thinking 1 2 3 4 5 NA • Summarizes history findings 3. Conducts physical exam appropriate to 1 2 3 4 5 NA ESSENTIAL patient complaint • Abdominal Examination. Identify if presence • Chooses systems appropriate to or absence of distended bladder, irregularities presenting complaint and history to shape of bladder or renal mass. Provides useful information in formulating his list of findings differential diagnosis and evaluated • Conducts an organized sequence complications for those conditions. of exam to minimize position • Rectal and prostate examination. DRE permits changes yet promotes examiner abnormalities in size, consistency, contour, efficiency and tenderness of prostate gland to be • Communicates to the client the identified. Important to remember, when exam technique instructions and prostate gland is responsible for patient’s findings symptoms, its oval size does NOT correlate well with the severity of these symptoms. • Order of exam techniques Specific attention should be made to tone of (inspection, auscultation, anal sphincter. Generally accepted that percussion, palpation) strength of the anal sphincter tone correlates • Performs techniques correctly with strength of urinary bladder sphincter tone. • Genital examination. Assess for abnormalities that lend support for or against conditions on list of potential diagnosis along with information regarding coexisting conditions (phimosis, hypospadias, epididymitis, or urethritis) that might contribute to nocturia. NONESSENTIAL • Skin Examination. There are very few urogenital skin concerns that can cause specifically nocturia. Dysuria if noted could be related to a skin secondary infection or other cause. • Heart and Lung Examination. Ideally, a heart and lung examination should be performed on all patients regardless of the reason for the clinical encounter; however, in the “real world” time constraints in the clinical setting, we want to focus on the areas that with provide the best “bang for the buck”. Therefore the only essential H and P points need to provide the most useful clinical information for guiding diagnostic studies and formulate correct diagnosis and treatment plans. 4. Demonstrates ability to summarize 1 2 3 4 5 NA Differential Diagnosis: BPH, Prostate CA, Caffeine history and physical findings in a manner Overuse, Medication Adverse Symptom, Bladder to provide a list of differential diagnosis Cancer, Colon Cancer, Phimosis, epididymitis, urethritis, and possible primary diagnosis (es) urethral tumor, DM, Diabetes insipidus, heart failure, cystitis, pyelonephritis, glomerulonephritis, renal cancer, staghorn calculus, renal trauma, lower UTI, nephrolithiasis. 5. Critically considers diagnostic work up 1 2 3 4 5 NA Essential pertinent or necessary to patient problem • UA. Evaluate for systemic diseases (DM, diabetes insipidus, heart failure); infectious process of urinary tract (cystitis, pyelonephritis, glomerulonephritis); renal abnormality (renal carcinoma, stone) 86 • PSA. Most experts agree that if the PSA score is below 4.0, the likelihood of prostate CA is very small. However, if greater than 10, likelihood is much higher. No consensus on levels from 4 to 10. Risk factors for prostate cancer include advancing age, positive family history, African American, smoking, unhealthy diet (including red meat, high fat), and low fiber (vegetables). • Serum Creatinine. Generally proportional to renal function. All older men with urinary symptoms should have a creat to ensure kidney function is not compromised or contributing to their condition. Nonessential • PVR – Marked BPH can cause obstructive uropathy. Depending on clinical guideline – AUA SI score noting moderate to severe BPH symptoms should be screened. Other experts note not needed if H and P are consistent with diagnosis of BPH and without evidence of obstructive uropathy. • Prostatic US Today – Not indicated based on benign exam findings. However, if abnormal PSA, then further consideration advised prior to Urology Consult. 6. Interprets diagnostic data accurately 1 2 3 4 5 NA 7. Considers cultural variations that will 1 2 3 4 5 NA impact patient management Resource Utilization 1. Employs current and dated references 1 2 3 4 5 NA 2. Exhibits proficient use of web-based 1 2 3 4 5 NA references 3. Demonstrates use of evidence-based 1 2 3 4 5 NA medicine Patient Management Plan 1. Provides most probably diagnosis(es) 1 2 3 4 5 NA Essential for patient encounter BPH, increased symptoms due to antihistamine use. 2. Articulates effective patient education 1 2 3 4 5 NA Essential concerning management plan, follow-up, • Stop Antihistamine. Consider nasal atrovent and preventive care as appropriate or nasal steroid instead. • Start Tamsulosin 0.4 mg 30 minutes before bed, can increase 0.8 mg if patient tolerates and continues to be symptomatic. • Scheduled for Prostatic US – if abnormal, or not improvement with medication, refer to urology. • Risks and benefits of medication. • Follow-up recommendations 3. Chooses appropriate pharmacologic 1 2 3 4 5 NA and/or non-pharmacologic interventions 4. Demonstrates consideration of use of 1 2 3 4 5 NA collaborative patient management 5. Includes patient education at 1 2 3 4 5 NA disposition as well as at teachable moments in patient encounter 6. Arranges referral or consultation in 1 2 3 4 5 NA effective manner 87 Final Summary Final Evaluation 1 2 3 4 5 PASS FAIL

Final Comments

Adapted from: Scott, P.M. (2012). Cases in Clinical Medicine. Sudbury, MA: Jones and Bartlett Learning, LLC.

Tool Definitions

1 - Novice: Knows the general rules to help perform tasks; relies on guidelines/standards on which to base treatment/management, rather than on previous past experience. Student: Requires guidance to determine which guidelines/standards to choose; beginning to develop differentials, recognize some normal versus abnormal conditions.

2 - Advanced beginner: Has had some prior experience with which to frame judgements and formulate management plans; requires supportive cues but less so than beginner stage. Student: Increasingly independent in their ability to develop a differential list and use guidelines/standards to formulate a management plan; increasingly recognizes normal versus abnormal conditions.

3 - Competent: More past experiences upon which to base their clinical reasoning and judgement; developing the ability to prioritize care and formulate management plans; gaining efficiency in clinical practice. Student: Increasingly independent in their ability to develop a differential list and use guidelines/standards to formulate a management plan; increasingly recognizes normal versus abnormal conditions (in specific populations); starting to recognize the need for consultation and referral.

4 - Proficient: Able to anticipate patient course from previous experience; ability to prioritize care and formulate management plans based on previous experience; efficient clinical practice; developing intuition. Student: Independent

88 in their ability to develop a differential list and use guidelines/standards to formulate a management plan; recognizes normal versus abnormal conditions in most populations; recognizes the need for consultation and referral.

5 - Expert: Confident; solid knowledge base on which to formulate judgements and develop management plans; intuitive ability to quickly read patient situations. Student: exceptional in their ability to perform independently; intuitive grasp of patient situations; recognizes the need for consultation and referral.

References

Burns, C., Beauchesne, M., Ryan-Krause, P., & Sawin, K. (2006). Mastering the preceptor role: Challenges of clinical teaching. Journal

of Pediatric Health Care, 20(3), 172-183.Latham, C. L. & Fahey, L. J. (2006). Novice to expert advanced practice nurse role

transition: Guided student self-reflection. Journal of Nursing Education, 45(1), 46-48.

Copeland, H. L., & Hewson, M. G. (2000). Developing and testing and instrument to measure the effectiveness of clinical teaching in

an academic medical center. Academic Medicine, 75(2), 161-166.

Latham, C. L. & Fahey, L. J. (2006). Novice to expert advanced practice nurse role transition: Guided student self-reflection. Journal

of Nursing Education, 45(1), 46-48.

Scott, P.M. (2012). Cases in Clinical Medicine. Sudbury, MA: Jones and Bartlett Learning, LLC.

89 Appendix K Preceptor Thank You Letter

Noted below is a copy of the Preceptor Thank You Letter that is sent out to each University of Mary Preceptor on University of Mary Letter Head. Preceptors also have the option of becoming a Clinical Practice Professor. Students are encouraged to communicate these benefits with their preceptor and consider this opportunity after they graduate and are eligible to also become a University of Mary Preceptor.

Dear Preceptor,

Thank you for your contribution to the clinical and professional development of Student during the summer semester of XXXX school year for xx clinical hours. The University of Mary appreciates how you honor the professional duty of mentoring the next generation of healthcare providers. We have high standards for our students and realize that in order for them to reach their full potential they need the challenge and guidance of professionals such as you.

Please keep a copy of this letter for your records. It serves as documentation of the number of hours worked with a student. These hours may contribute to your recertification application to some national certification bodies (i.e. AANP and ANCC).

Please know your service is appreciated by not only Student, but also by the entire University of Mary Family Nurse Practitioner Program faculty. The time and energy you expend as a preceptor is significant and we want to recognize your efforts. For your contributions, the University of Mary bestows upon you the title of University of Mary Clinical Practice Professor and encourages you to use this title as part of your professional documentation. A definition of the Clinical Practice Professor role at the University of Mary can be found at this link.

I am excited to share with you that Clinical Practice Professors are provided eligibility for University of Mary tuition benefits, access to the Welder Library, and opportunities for free continuing education. Information related to each of these benefits are provided in the links below: • University of Mary Tuition Benefit – Preceptors are eligible for 100% discount on 8 semester hour credits/year for undergraduate degree credits and 50% graduate degree credits (classroom setting) and 50% tuition benefit for online undergraduate and graduate degree programs. Preceptors who would like to take advantage of this option are encourage to contact Dr. Billie Madler, Chair of Graduate Nursing Education at 701-355-8266 or by email at [email protected]. • Welder Library • Continuing Education Opportunities

We do require having on file a resume or curriculum vitae (CV) for all Clinical Practice Professors. If you have not previously provided a copy, forward your resume or CV to me at [email protected].

Please know we will always welcome your ideas. If you have any recommendations for our program or comments regarding your time with our student, please feel free to contact me. Also, if you should need any additional documentation of your hours spent with our students, I can be reached at 701-319-1101 or by email at [email protected]. I look forward to continuing our partnership in this exciting and rewarding venture.

With many thanks,

Annie M. Gerhardt, DNP, APRN, FNP-C FNP Clinical Competence Coordinator, Associate Professor Doctorate of Nursing Practice, Family Nurse Practitioner Program 90