I took a peek at my sitemeter and saw that a question about confidentiality brought someone to my site. I thought that it might be a good topic. So here goes…
In the medical field, any practitioner (MD, NP, nurse, CNA etc) must keep all information about a patient confidential. We all know about HIPAA and it’s restrictions regarding release of information in office and hospitals. Sometimes it can be a nuisance, but for the most part, it’s there to protect patient’s medical information.
The part of confidentiality that interests me the most is the fact that patients sometimes worry that we “blabber to everyone” their personal business. I tell my patients that ANYTHING said between me and them is strictly confidential. There are few exceptions such as homicidal threats or threats to self that I take seriously and would make sure that the MD is aware of.
I always want patients to understand that they can talk to me about any subject without being embarrased. This is sometimes an issue with men regarding erectile dysfunction issues and such, as it is for females speaking to a male MD. If someone is uncomfortable speaking with me, I never feel bad about sending them to whomever they feel comfortable with. Most do stay and talk once I explain that “I’ve pretty much heard it all and there’s no way to embarrass me.”
Sometimes, it’s important to have separate visits for spouses to make sure that if there are any issues that need to be addressed can happen. This is especially true for spousal abuse potential. This goes for husbands and wives. Abuse is an equal opportunity problem.
Just remember, make your patients comfortable and they will tell you the really imporant things about their health and you may save a life!
Hello to all! I wanted to get to the end of my first week before I updated. I decided to take a position in a rural health clinic about 25 minutes from my home. It is an internal medicine practice that sees patients from 12 years old and up. The majority of patients are 45-90’s. It’s a small clinic with three exam rooms. It will be interesting to see how it will work when the doctor and I are both seeing patients at the same time. I hope that it gets busy enough to move to a bigger office someday.
This week has been a little quiet because the clinic was closed for a few weeks and it gave me a chance to see how things are done in this practice. I really like the people that I work with! The doctor is good about answering questions and has made me feel very comfortable. He will be working in a VA hospital for a week at a time, so he won’t be in the clinic much during that week at all. He has reiterated to me that I am the provider and that I need to make sure that the office runs smoothly when he’s not there. This won’t be a problem because the girls and I get along very well.
As you can see, I have updated my profile and put up my graduation picture. I felt like it was time to come out of the shadows after much thought. I feel that if I want to be taken seriously in the blogging world, I need to be more like the other great nursing bloggers that I like. I have made every effort to make sure that patient confidentiality is maintained as usual due to the rules of course. So here goes! Drum roll please!!!!
NPs Save Lives is actually…..
Jennifer Scott ARNP-BC
It’s very nice to meet you all!
Below is a sample visit template.
Patient:
Date 13 June 2006
Present Illness/ Review of Symptoms:
Patient presents today with…
Review of Symptoms: A 14 point review of symptoms is otherwise negative.
Physical Exam: Vital Signs: Stable see chart
General Well Developed well nourished, positive affect, no acute distress.
Neuro: Alert and oriented X 3, Cranial nerves II-XII grossly in tact, MAE without difficulty, negative ataxia or cerebellar signs, normal gait and sensorium.
HEENT: NC/AT, eyes clear, TMs clear with visible landmarks, Nasal septum midline with patent nares, oropharynx clear, mucous membranes moist, the maxillary and frontal sinuses are non tender to palpation.
Neck: Supple, full ROM, no JVD, no thyromegaly, no lymphadenopathy.
Lungs: Clear bilaterally, regular equal and unlabored, normal rate and depth of respiration.
CV: S1 and S2, no murmurs, regular rate and rhythm.
Abdomen: Non distended, Non- tender to palpation, bowel sounds present X 4 quadrants, no focal signs, no HSM. GU: No CVA tenderness. Skin: Warm and dry, no rash or xanthem noted. Extremities: No edema, negative Homan’s sign, 5/5 strength upper and lower extremities.
Diagnostics:
Assessment
Plan
Patient was educated regarding the treatment plan, and was instructed to seek care immediately in case of changing or worsening symptoms. As always, we remain available for questions or concerns.
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