NR511 WEEK 1-3 LECTURES (NR511)

Exam (elaborations) NR511 WEEK 1-3 LECTURES (NR511) Primary care is different than tertiary care. The types of problems that are solved in primary care are different than those seen in acute- or critical-care settings, which you may be used to as a bedside nurse. Upper respiratory infections, abdominal complaints, skin rashes, and vague somatic complaints are problems that are not often encountered in the hospital setting. Even chronic conditions present differently in primary care. HTN, CHF, arthritis, and DM present with day-to-day management problems that are different from the crises that acute-care nurses must respond to in a tertiary-care setting. As you will soon find, primary care is a new world with a different set of problems to be solved, different kinds of constraints on choices, and a different culture of care. Diagnosing and treating up to 30 different patients or families in a day is both challenging and mentally exhausting. Although an office visits allows for focused one-on-one care with an individual patient, the NP must still recognize that healthcare is a business. In order to meet office overhead costs, including provider and staff salaries, the business must be profitable or at least have equal income to operational cost margins. Because of this, a nurse practitioner needs to have a solid understanding of how to obtain and process information in an organized approach. Learning to practice primary care in an artful way requires a certain kind of thinking. The mental task of eliciting and sorting through large amounts of data, clustering data elements into meaningful patterns, connecting patterns to reasonable diagnostic statements, considering risk factors, and selecting appropriate interventions require a high level of diagnostic reasoning. Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves the process of questioning one’s thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others. Developing expertise as a nurse practitioner takes time. Students who are experts in hospital or specialty care become novices in the advanced practice role. Clinical judgment and diagnostic reasoning is based on experience. As a student, you will hopefully gain skills to function at the advanced beginner level through didactic work and the added clinical practicum experience. It took years for you to become an expert nurse, so you can expect that it will take years to become an expert NP. On your journey towards graduation from the FNP program, you will be given the necessary tools to help you be successful on the board certification exam and become a competent advanced beginner. The type of data that you collect depends on the type of visit. Most visits are episodic or problem-focused where 1 or 2 specific issues need to be addressed. One thing I want to point out is that the information in the H&P should only be relevant to the complaint or problems that you are addressing. So, a patient with only a skin complaint does not need a full H&P. Rather, a focused history and exam as it relates to the skin complaint or associated symptoms should be recorded. First, I want to go over two important, distinct concepts that seem to be an area of confusion for many students: subjective and objective findings. We will discuss these in more detail when we introduce the SOAP note lecture. NR511 WEEK 1-3 LECTURES To start, subjective information is what the patient: 1) reports, 2) complains of; or 3) tells you in response to your questions. Examples of subjective information include the following:  Constitutional: fever, chills, lethargy, weight loss or gain, and so on  HEENT: headache, blurred vision, otalgia, sore throat, and so on  Neck: swollen lymph nodes, and so on  Lungs: SOB, cough, wheezing, and so on These are all examples of subjective information. Subjective information is the S part of the SOAP note, which includes CC, HPI, and ROS, as these are all things that the patient reports to you in an interview. Objective information is what you can see, hear, or feel as part of your clinical exam. It also includes laboratory data and test results. Examples of objective information include the following:  Constitutional: well-developed, well-groomed, thin, cachectic, obese, and so on  HEENT: Normocephalic, PERRL  Neck: anterior cervical lymph nodes are swollen and tender  Lungs: clear, wheezing in RLL, bronchospastic cough  Results: you might list the CBC, strep test, U/A, CXR, CT, and so on Objective information is the “O” part of the SOAP. Eliciting a detailed patient history through open-ended questioning and active listening offers critical clues to determining a diagnosis. Obtaining a meaningful history involves collecting subjective information and organizing it into meaningful chunks of knowledge. Data acquisition in history taking is most effective if it is hypothesis driven. In other words, when the information selected and gathered is related to the list of possible diagnoses. Hypothesis-driven data means that data that would confirm or disprove a specific hypothesis are specifically sought and recorded. However, obtaining data that fit one possible problem is not enough. Competing hypotheses must be ruled out by seeking additional data, and the provider needs to consider that the priority list of hypotheses may change based on new information. For example, symptoms of runny nose may be due to a viral infection. If in the history- taking the provider specifically asks if these symptoms have occurred before and the patient replies, “Yes, this also happened 2 weeks ago,” the likelihood of a viral infection decreases and the likelihood of an allergy increases. In other words, your hypothesis for the etiology of rhinitis has now changed. The chief complaint (CC) is a one-to-few word statement identified by the patient as the reason for their visit to you today. Try to identify the chief complaint in this scenario: Johnny, a 5-year-old, is brought to your office by his mother. The mother reports that the school nurse called because Johnny said he had a tummy ache. Several other students in the school also have complained of some GI symptoms. He did not throw up, but he says he feels like he could. In this case, an acceptable CC would be nausea or “tummy ache.” It’s short and to the point. You will expand on information about the chief complaint in the history of present illness (HPI). The HPI is a detailed breakdown of the CC, written out as the OLDCARTS acronym. Each letter in the acronym represents important information about the CC, which will help you to develop a differential diagnosis. The HPI is focused on the CC only, so each letter of the acronym should address that one issue. Any additional information that you feel is pertinent to report in the case but is not directly related to the CC should be reported in the ROS. HPI O: Onset of CC L: Location of CC D: Duration of CC C: Characteristics of CC A: Aggravating factors for CC R: Relieving factors for CC T: Treatments tried for CC S: Severity of CC There are two things I want to point out here. Do not get confused on duration. Duration is not referring to the onset of the symptom. Rather, it is an assessment of whether the symptom is constant or if it comes and goes. Also, don’t forget to ask about severity. Severity refers to the level of pain (such as reported on a pain scale) or how the symptom has impacted the patient’s ability to go to school, to go to work, or to perform their daily routine. This should be included in every HPI. Be sure to watch the video lecture on the ROS, which is again, assessment of subjective information. Because you have successfully completed NR509, it is expected that you are competent in performing a head-to-toe physical exam. Although some of your patients may present for a complete physical where you need to address all of the body systems, you must now learn to focus your assessment skills to be appropriate for the patient’s complaint and history as part of a problem-focused visit. This will become clearer as you go through the lecture on billing and coding. Differential diagnosis, or differential, is a list (single) of plausible diagnoses (plural) that fit the historical and clinical presentation of your patient in order of priority. This is different than the problem list, which is a list that includes all of the active medical problems for the patient. You will be seeing these in your clinical rotations, but for the purposes of your first clinical course, we will not be putting together problem lists. The focus in this course is on how to formulate a differential diagnosis. There is a separate video lecture on the differential diagnosis for you to view this week which presents the concept of formulating a differential diagnosis in a meaningful way. Diagnostic tests can be used to confirm or to rule out hypotheses. They may also be used to screen for conditions or monitor the progress in managing a chronic condition. Diagnostic tests vary in usefulness based on sensitivity, specificity, and predictive value. When we describe the specificity of a test, we are referring to the ability of the test to correctly detect a specific condition. If the patient has the condition but testing is negative, we describe this as a false negative. If the patient does not have the condition but the test result is positive, this is considered to be a false positive test. When a test is very sensitive, we mean it has few false negatives. The higher the sensitivity, the lesser the likelihood of a false negative. A sensitivity of 99% means that it is very unlikely for a false negative result. In a perfect world, a test would have 100% specificity and sensitivity, but we know that it is not the case. Therefore, it is important to consider the specificity and sensitivity of a test when considering its usefulness in ruling your hypothesis in or out. Predictive value is the likelihood that the patient actually has the condition and is, in part, dependent upon the prevalence of the condition in the population. If a condition is highly likely, a positive test result is more likely to be accurate. If a condition is very unlikely, a positive test needs to be questioned and perhaps additional testing would need to be done. When deciding whether or not to order a test, five things must be considered.  Cost  Convenience  Sensitivity  Specificity  Risk of missing a condition (predictive value) In today’s healthcare system, patients are encouraged to be proactive and informed members of the healthcare team. One method that is advocated by popular groups such as AARP, the NIH and the CDC is for patients to create a list of questions or issues for their provider visits. Lists can be challenging for providers because many patients have the unrealistic expectation that their provider will address every item on the list. You will see this frequently in your practicum rotations. The reality is that the medical office is still a business, and time constraints often prevent providers from addressing every issue in one visit. Prioritizing the patient’s needs while maintaining the allotted time requires a patient-centered communication approach. Although you may not be able to cover the list in its entirety, this approach acknowledges to the patient that you hear their concerns and together have developed a plan to address them. This tactic not only improves patient satisfaction but helps keep the provider on schedule. In the next few slides, we will be discussing a useful approach to prioritizing a patient’s list. Keep in mind that these are suggestions and not rules. At the beginning of each practicum rotation, I encourage you to discuss with your preceptor how he/she deals with this issue. Some offices may have a policy in place or the provider may have a personal preference in handling prioritization of patient’s lists. These suggestions may not be the best approach for the practice setting that you are currently in but may be useful in another office or in your own practice. Acknowledge the patient’s list of questions and concerns. It is important to acknowledge that the patient took the time to prepare for the visit in compiling a list. This can be done simply by stating “I see you have a list of concerns (or questions), let’s look at it together. Mutually negotiate what to cover during the visit. If the patient’s list is too long or does not match your own priorities for the visit, you will need to negotiate which items you will address at the current visit. The key to the negotiating process is to use positive language. So, instead of saying “we don’t have enough time to discuss all of these”, a better approach would be to say “I would like to cover as much as we can from your list, but I also want to take a few minutes to talk about your (diabetes, HTN, COPD, etc). Be honest. Being honest about the time allotted for the visit while planning jointly on how to use that time is important. To take this approach, you might say “Since this visit is only scheduled for 15 minutes, let’s decide on the 3 most important issues for today.” Most patients are willing to accept this but occasionally there will be a more demanding patient. In cases such as this, being honest and telling the patient that in covering all of the issues, you cannot be as thorough. Make a plan for follow-up. Mutually set an agenda and time frame for the next visit. Recap what you were not able to address at this visit and what you intend to go over the next time. If a patient is overdue for an annual physical, you might make the recommendation that one is scheduled since more time is typically allotted for these visits. Be sure to document this plan in your note as a reminder to you for the next patient visit. All healthcare providers are called to provide evidence-based care, which involves providing care and making treatment and screening choices based on current research findings. Generally, EBP refers to using research findings from multiple studies that are convincing enough that a consensus is formed recommending the findings be used for clinical decision-making or practice guidelines. EBP also involves inclusion of patient and provider preferences, patient values, and cultural considerations in the clinical decision-making process. Guidelines should be followed in the majority of cases unless there is a clear rationale for deviating from them to serve the particular needs of the patient. There are some examples of Clinical Practice Guidelines/Evidence-Based Guidelines developed by organization or agencies that I have listed here. Some examples are: For allergen and immunotherapy, the American Academy of Asthma and Allergy group is one example. The Infectious Disease Society of America is also another group that puts out clinical practice guidelines. Now that you understand each individual component of the history and physical, it is time to document and record your information in a SOAP note. SOAP notes are used to provide accurate information about the patient’s status and the visit. They include the subjective and objective findings from the history and physical as well as your assessment (or diagnosis) and plan. Please view the video lecture on SOAP notes. Hi. In this brief presentation, we will be discussing the importance of influences on health promotion. There is an opportunity for disease prevention, screening for high-risk problems, and health promotion at every visit. There are three levels of prevention: primary, secondary, and tertiary. Focusing healthcare efforts on all three levels of prevention is important, but primary prevention has become the ultimate goal of health promotion. Primary prevention is the prevention of disease. Examples: Health education, immunizations, use of sunscreen and seatbelts, nutrition counseling, weight control, stress reduction, exercise, etc. Secondary prevention is the detection of a disease through its very early stages through early screening. Examples of this include skin cancer and breast cancer screening, testicular selfexam, HTN screening, cervical cancer screening, pediatric developmental screening, and Fecal Occult Blood samples (FOB). Tertiary prevention is the restoration of health after illness or disease has already occurred in order to prevent further sequelae of the disease and complication. Some examples of this include dialysis and chronic kidney disease, chemotherapy in cancer, biologics in autoimmune disease, and statins for hyperlipidemia. The identification of risk factors is an essential component of health promotion. The key components to effective health promotion are to screen patients for potential known risk factors and to intervene when appropriate. Obviously, some risk factors are modifiable, and some are not. Nonmodifiable risk factors include age, gender, and family history, whereas modifiable risk factors include weight, level of physical activity, elevated cholesterol and blood pressure, stress level, and smoking. Early identification of both modifiable and nonmodifiable risk factors are integral so that patients also with modifiable risk factors can make changes to affect more favorable outcomes with a disease. One factor that influences health promotion is health literacy. Health literacy can be described as the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate healthcare decisions. Health literacy includes reading skills and comprehension, writing, listening, speaking, and conceptual knowledge. Assessing health literacy levels should be part of your daily practice so that you can identify patients at risk for misunderstanding instructions and for those who may not have the ability to adhere to recommendations. Although an entire day can be spent on this topic, this lecture is designed to teach you the basic elements that you will need in order to determine a level of service for each visit, which subsequently determines the level of payment to the provider. I’m sure I do not need to tell you that payment is very important in any business, even healthcare. Whether in a solo practice or group practice, providers must generate income to keep the practice afloat and, ideally, profitable. Unless you will be operating a nonprofit practice that is funded entirely by donations, there are universal rules that you must know in order to correctly bill for your services. I encourage you to speak more to your preceptors about the billing process while in your clinical setting. So you might ask, why is this important to me as a student? Understanding the levels of office visit billing is important to you as a student because this information should be reflected in your log of patient encounters and can be reviewed by faculty to ensure that you are seeing patients of all ages and complexities. We will get more into documentation of your encounters in the next lecture, but just know that it is important to accurately document the types of patients that you see in your clinical rotations. Now, let’s talk about the importance of documentation. The written history and physical (H&P) serves several purposes. 1. It is an important reference document that gives concise information about a patient's history and exam findings. 2. It outlines a plan for addressing the issues that prompted the visit. This information should be presented in a logical fashion that prominently features all data immediately relevant to the patient's condition. 3. It is a means of communicating information to all providers who are involved in the care of a particular patient. 4. It is an important medical-legal document. 5. It is essential in order to accurately code and bill for services. Currently in the United States, our healthcare system operates on a fee-for-service model. This means that a provider is given a set amount of monetary reimbursement for a specific visit or procedure performed that is adjusted for geographical location. Payment is dependent, though, on showing the necessity for the service provided to the payer by means of accurate documentation. Now, a payer can be a public or private entity. Private entities include insurance companies that you’re contracted with in your office, whereas public payers include Medicare and Medicaid. Medical coding is the use of codes to communicate with payers about which procedures were performed and why. Medical billing, on the other hand, is the process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider. In order to send a claim (or bill) to a payer such as Medicare, the provider’s documentation must be translated into alphanumeric codes and transferred to the payers. Keep in mind that only codes are submitted for each individual claim, which means you are not faxing your actual documentation over. Therefore, you want to be sure that the codes accurately reflect the type of service that you provided. There are two different designated coding systems that are used today, which were developed as a means to standardize terminology and simplify medical records. The first system is the Common Procedural Terminology (CPT) system, and the second system is the International Classification of Diseases method of coding and that’s known as the ICD system. The CPT system offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and nonphysician providers. CPT codes are recognized universally and also provide a logical means to be able to track healthcare data, trends, and outcomes. Each service or procedure is represented by a five-digit code that is presented in six sections, including  evaluation and management;  anesthesiology;  surgery;  radiology;  pathology; and  Now, we are going to move onto the second system used in medical coding, which is the ICD codes. Currently, we are in the tenth revision of the system, and, therefore, the classification system is known as ICD-10. ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide the payer information on the necessity of the visit or procedure performed. This means that every CPT code must have a diagnosis code that corresponds. Let me give you an example. Let’s say that when submitting my claim to a payer I used the CPT code 69210 to identify that I manually removed cerumen from the patient’s ear canal. Let’s also suppose that I listed one of the patient’s many diagnosis on the claim. For instance, here I listed I10 which is the ICD-10 code for HTN. Procedure Code (CPT) Diagnosis Code (ICD-10) 69210 I10 (HTN) Well, when the payer reviews this claim for reimbursement, the procedure is not likely to be reimbursed. Why you might ask? Because the diagnosis code that is tied to the procedure code does not explain its necessity. You see, payers are very particular in making sure that they are not giving money to providers for unnecessary procedures. So, in order for the claim for this procedure (cerumen removal) to be paid, I would need to attach a diagnosis code that explains the necessity. In this case, the ICD-10 code H61.20 gives the diagnosis of cerumen impaction, which is an appropriate reason to perform the procedure of the cerumen removal. Procedure Code (CPT) Diagnosis Code (ICD-10) 69210 H61.20 (Cerumen impaction) The takeaway message here is that every procedure code needs a diagnosis to explain the necessity whether the code represents an actual procedure performed or a nonprocedural encounter like an office visit. Understanding and accurately recording procedure and diagnosis codes are necessities in order for you or your practice to get reimbursed. As I said before, reimbursement is paid on a fee-forservice model where you are paid a certain amount based on the complexity of your work. In the United States, the Centers for Medicare and Medicaid Services (CMS) have what is known as the Medicare Physician and Nonphysician Practitioner Fee Schedule, which, in a nutshell, assigns a value to each CPT code for reimbursement purposes and this is also adjusted for geographic location. Although private payers vary in their reimbursement rates and policies, most are tied in some form to the Medicare system, so understanding Medicare’s rules for coding is essential. For the rest of this lecture we are going to discuss CPT codes as they apply to Evaluation and Management (E&M) coding. This is important to understand because you will be inputting this information as evidence for the types of patients seen in your clinical encounter logs. E&M coding is very complex, so my goal today is to teach you the high points of E&M coding in a simplified version so that when you go into your clinical setting you have a basic understanding of the requirements for each office visit level. This is not a substitute for a coding course but rather a demonstration of the key things you need to know. Thankfully, some EMR programs automatically compute the E&M code for you, but it is still important to know nonetheless. Before you can determine your E&M, code you must first identify the place of service, type of service, and the patient status. The place of servicerefers to where the service was rendered. There are several categories to choose from, but the two most common are the inpatient and outpatient settings. This is pretty straightforward. The type of service refers to the type of service provided. Some examples of types of services include consultation, hospital admission, office visit, and so forth. Again, pretty straightforward. As a student in your practicum rotations, nearly all of your places and types of service will be outpatient office visits. Finally, you need to identify the patient’s status. Patient status refers to whether or not the patient is a new patient or an established patient of your practice. By definition, a new patient is one who has not received professional service from a provider from the same group practice within the past 3 years. Conversely, an established patient has received professional service from a provider of your office within the last 3 years. So, let’s look at an example. Let’s say that Jane is scheduled to see you today for a CC of sore throat. She has a medical record on file in your system, and you see that her last visit was in 2012 with your partner, Dr. Tom. Is she considered an established patient or a new patient? She is considered a new patient because even though she has been seen by someone in your office previously, it has been more than 3 years since her last visit. Here’s another example. John has been seeing you at your office for 20 years. He informs you that his mother is ill and he is moving to Florida to care for her. 18 months later, he returns to your office requesting a refill on his antidepressant (which he was not on when you last saw him). He informs you that he was being treated by the provider in Florida but that he decided to move back to the area after his mother died. Should John be considered a new or established patient for this office visit? If you guessed established, you are correct because even though he began treatment with a different provider in Florida, his return visit to you today is within that 3- year timeframe. Okay, so let’s discuss how you choose the right E&M code. There are several E&M codes that are available to choose from for an outpatient, office-based visit. The codes are chosen based on patient status (whether this is a new or established) as well as the complexity of the visit. The codes are ordered from lowest complexity to highest. So, 99205 and 99215 are the highest levels of complexity for a new and established patient, respectively. Outpatient-Office Visit New Established Minimal/RN visit Problem focused Exp. problem focused 99203 99213 Detailed Comprehensive Once you have determined the status of the patient (new or established), you then can then determine which one of the five E&M codes correspond with the visit. To do this, we are going to apply the principles of risk-based coding. There are three key components that determine risk-based E&M codes. 1. History 2. Physical 3. Medical Decision Making (MDM) Each one of these components (history, physical, and MDM) must have a specific number of elements documented to meet the visit requirements. Let’s look at the history requirements first. For example, for an established patient level two visit (99212), which is considered a problemfocused visit, your documentation of history must show the following. HPI One to three elements ROS N/A PFSH N/A CC Required For a higher level of service such as a 99214, which is considered an established detailed visit, more elements from the history are required. HPI Four or more elements of OLDCARTS ROS Two to nine elements from any of the body systems PFSH Three elements from previous, family, or social history CC Required Similar to the history, your physical exam documentation must show a specific number of required elements to meet the level of service code. For the 99212, code your PE documentation must include a minimum of the following. PE One to five elements from a single body system With the 99214 code (the higher level visit code), you must show the following. PE At least 12 elements from a single body system Although you will not be required to know the requirements for each visit level for an exam, you must be able to understand and communicate that each level has a minimum requirement of H&PE elements that must be met and that the higher the level, the more documentation required The third element that is needed to determine the level of a visit is MDM. Medical decision making is another way of quantifying the complexity of the thinking that is required for the visit. Complexity of a visit is based on three criteria.  Risk  Data  Dx Let’s go over those principles again. There are three main components in determining the E&M code: the Hx, PE, and MDM; and there are 3 key elements to medical decision making, which are risk, data, and diagnosis. E&M Code Hx PE MDM Risk Data Dx Now, medical decision making is a special category. Why is this so important? Well, the MDM score gives us credit for the excess work involved in management of a more complex patient. Here’s an example. Let’s say you have two patients with a sinus infection that will require antibiotic therapy. The first patient is a 15-year-old healthy teen with no known medical problems and is on no medication. The second patient is a 72-year-old man with uncontrolled diabetes, CKD, and HTN. He is also on a list of medications as long as your arm. In the first case, the medical decision making is pretty straightforward. Meaning, you write a RX for an antibiotic after considering the history and physical. There are no data to review, and the patient has a single diagnosis for the encounter (sinusitis). Now, let’s consider the older gentlemen. When deciding on an antibiotic for this person, a lot more has to be considered. For instance, drug-to-drug interaction would have to be checked. Because the patient has known CKD, you need to take into account his current renal status when choosing an antibiotic because a dose adjustment may be required. While you are doing this, he informs you that he needs you to write a prescription for his metformin. He has been out for at least 3 weeks. So, in addition to writing the antibiotic prescription, you now are renewing a prescription for his metformin. But when you look back at his most recent labs, you see that his A1C wasn’t at goal even on the metformin. So, now you need to add some more labs or ask some additional questions about home BG monitoring, diet, and so on, or consider switching him to a diabetic agent. Do you see where I am going with this? It’s definitely a more complex case. Now, would you expect to be reimbursed the same amount for each of these patients? The answer is obvious. The medical decision making involves more time and complexity, and because of that, a charge for a higher level of service (or greater reimbursement) can be justified. However, and I cannot stress this enough, your documentation must match the requirements for that level of service. If you are audited and your documentation does not support the level of service, then this is considered to be fraud and is subject to repayment of fees, additional fines, and sanctions, and this is just one reason documentation is so important. To confuse things a bit more, there are different codes for patients being seen for a complete physical exam. These are considered preventative visits, and additional reimbursement applies for your time spent on assessing health risks and providing education. Using the correct codes in your clinical encounter log is especially important because it provides evidence of the population of patients that you have seen. When faculty review your log, we will be looking for both preventative and complaint office visit codes across all age groups. I have included a list of commonly used preventative and complaint codes in a separate document. There are numerous tools available on the Internet that can be used to evaluate whether your documentation supports your level of coding for the visit. There is also a comprehensive table in your Chapter 22 of a chart audit tool that encompasses the same principles discussed. Finally, there are numerous smart phone apps that are available for the same purpose. I hope you found this introduction to billing and coding lecture to be helpful as you embark on your practicum journey. Hi, it’s Dr. Tracy Murray again and now we are going to move on and discuss clinical preparedness. Clinical rotations are an exciting time for students as this means that you are now one step closer to becoming an APN. In order to be successful, you need to be prepared, so in this lecture, we are going to discuss everything you need to know about your clinical rotations and the expectations for this course. I would like to start off by going over the clinical requirements to complete the FNP program. There are five clinical courses: NR511, 601, 602, 603, and 661. Each of these courses has a didactic component as well as a clinical component. NR511 Differential Diagnosis and Primary Care NR601 Primary Care and the Maturing and Aged Family NR602 Primary Care of the Childbearing and Childrearing Family NR603 Advances Clinical Diagnosis and Practice Across the Lifespan NR661 APN Capstone Course At Chamberlain, we are committed to providing you the best opportunity to successfully complete the FNP program and pass the national board certification exam. In this program, your clinical experiences play a significant role in that preparation, and a well-rounded clinical experience is the key to success. As a result, the clinical requirements of the program have and may continue to change over the course of time while we continue to evaluate the success of our previous students. Right now the current requirements are as follows. For NR511, NR601, and NR602 there are three options. You can do an Internal medicine rotation which will require a separate pediatric rotation before the completion of your program. You can do Family Practice. You can also do Pediatrics for 1 session knowing that you will have to do a minimum of 2 courses in either Internal Medicine or Family Practice before your program ends. For your last two courses, we allow certain specialty primary care sites, as long as you make sure that you have satisfied the pediatric and primary care requirements. Some of the options here include: Urgent Care, Retail Clinic, College Health Center, Prison, Home Health Centers and Mobile units for instance. Practicum sites need not correspond with the topic of the current course, but at the end of your practicum preparation you must demonstrate (through documentation) achievement of a wellrounded clinical experience. Let’s discuss what we mean by a well-rounded experience a little further. Both state boards of nursing and the National Certification Exam bodies can ask to audit your clinical hours when you apply for testing and licensing. If they feel you don’t have a varied enough experience across the lifespan, they can refuse to allow you to sit for your exam or be licensed as a family nurse practitioner. (A rule of thumb for them is 15% of peds and 15% of women’s health exposure of total clinical time in a program.) Be aware that just because you are planning to stay at a family practice (FP) site for all rotations does not automatically mean that you will get the appropriate exposure to all age groups and acuities. Although faculty does review and approve sites prior to your rotations, we cannot guarantee that all populations that you see will be represented in the patients that you have exposure to. For example, some FP offices may offer services for children at the age of birth or two weeks but they might rarely have the opportunity because a lot of families go to pediatricians. Additionally, some FP offices only allow children of certain ages or a minimum age, such as 2 years old or 5 years old 5 years and up, or they may not provide vaccinations for school-aged children. If you stayed at a site that have these restrictions for all 5 courses you would be missing opportunities. All students are subject to review of clinical logs to ensure that they have received a wellrounded experience. It is the responsibility of you, the student, to seek out the experiences that you are lacking. This may require a delay in your progress and an alteration in your clinical plan. Ultimately, it is your responsibility to determine if you have obtained the needed exposure before graduation. Although there are no set numbers of types or ages of patients seen, a true wellrounded experience will include both children from birth through young adult visits for well child and acute visits, as well as adults for wellness and acute or routine visits. You should also be able to display a variety of decision-making complexity by means of documenting the office evaluation and management (E&M) code for the visit. As you should recall, the higher the level of code, the higher the complexity of the visit (99201–99205; 99211–99215). The majority of your clinical time should be spent in the outpatient, primary care setting. However, rounding on patients in the hospital is permitted under the following circumstances.  Your course instructor must be made aware that you’ll be rounding.  The preceptor has facility privileges where the rounding will occur.  Patients seen in a facility are patients of the provider’s outpatient practice.  The student actively participates in the patient’s care (which means you can’t take credit for observing.  Time spent is no more than 25% of total practicum hours for that course. The clinical portion of each practicum course is pass/fail. In other words, you cannot pass the class if you do not successfully complete all requirements of the clinical practicum. There are no additional points given for meeting the requirements. The non-graded clinical components include:  You have to complete a minimum of 125 hours of patient care in the practicum setting.  You have to have a successful midterm and final evaluation from your preceptor and course instructor.  You must submit an evaluation of your clinical site and preceptor.  And then you also have to show your clinical experiences by means of a database or clinical program that we are using the student data entered, faculty can view a student’s progress in their clinical activities and note whether students are meeting course objectives Clinical time is based on patient care hours, not “clock time,” and includes the time spent prepping for the patient encounter (so chart review & lab reviews, etc.). Time spent discussing a plan of care, writing the SOAP note and any teaching that the preceptor provides. You are also allowed a maximum of 15 “alternative hours” per course but they must fall into one of three approved categories: telephone management, prescription refills, or lab review. Make sure that you input your patient time accurately. For NR511, you should be seeing at least one (1) patient per hour. As you move through the subsequent rotations, your time spent with each patient visit should decrease. You’re expected to enter at least 50 encounters or 50 hours prior to midterm and a minimum of 125 hours by the Wednesday of Week 8 in order to pass. Your clinical log represents your experience, therefore every patient encounter should be documented. Data for each encounter should include  date of service;  age;  gender and ethnicity;  visit E&M code (e.g., 99203);  chief concern;  procedures;  tests performed or ordered;  diagnoses; and  level of involvement (mostly student, mostly preceptor, together, etc.). Clinical logs are legal documents and they demonstrate your exposure and expertise in learning. Once a course is complete and your final grade is given, the clinical logs are closed. So you may not amend, add, or delete encounters for that course. If you are found to have altered your clinical logs after a course has ended, you will have violated the Academic Integrity Policy and you will be subject to sanctions up to and including expulsion from the program. You may or may not be allowed to document in the EMR at your clinical setting. If you are, you must complete any required training by the facility. This is not considered to be patient care and cannot be counted towards clinical time. In some instances, preceptors prefer to write or submit the notes themselves. If this is the case, what you should do is write your version of the encounter in a SOAP note format on your own and ask your preceptor to review it if time allows. Before we talk about your responsibilities as a student in the clinical setting, I want to take a moment to discuss what Chamberlain’s qualifications and responsibilities are that we expect of the preceptor. First of all for Advanced Practice Nurses they either have to be Masters or Doctorally prepared APNs with an unencumbered and current state license. They have to have a National Board Certification in their area of specialty and they must have a minimum of 1 year of experience in their APN role. Now, PAs have to be Masters or Doctorally prepared also with an unencumbered and current state license. They also must be Nationally Board Certified, they must also have a minimum of 1 year experience in their role but they also have to have a supervising physician that is contracted with them and that physician’s paperwork must also be submitted. For physicians, they need only an unencumbered and current license to practice as a physician in the area of specialty So let’s talk about the preceptor responsibilities. We expect that the preceptor should do the following.  Arrange a schedule with the student for completing the necessary hours.  Give the student an orientation to the site early in the experience. This will facilitate a smooth transition into the site and optimize the use of available resources.  Provide appropriate office space and office materials for the student, if necessary.  Explain their expectations of the student: The areas of dress, conduct, scheduling of hours, and general characteristics of the experience should be discussed.  Allow sufficient time for supervision and instruction in the form of routine interactions. Guide the student in his or her next steps, and ask to review work periodically.  Provide the student with constructive feedback.  Afford the student the time and patience needed for an optimal learning experience. Now, on the other hand, students must remain compliant with their immunizations, drug screening, CPR, and HIPAA throughout all their clinicals. If your PPD, tetanus, flu immunization or CPR expire, you cannot go to your clinical site until they are up to date. There is no grace period. It is expected that all students will arrive at their clinical site appropriately clean, dressed and groomed. An IRONED and CLEAN lab coat is usual unless you are directed not to wear one by your preceptor. The lab coat must have the Chamberlain College of Nursing patch neatly affixed to the coat. Your CCN student ID badge should be worn at all times and your name and picture should be visible to the patient and staff at all times. Professional attire for women is expected and this includes conservative jewelry consisting of small earrings, no more than two pair, no other visible piercings, no tongue jewelry. Low key makeup and no artificial nails. Nails should be well trimmed and not extend beyond one-quarter inch from the end of the finger. If nail polish is worn, it should be neutral. Tops should cover the abdomen at all times (Hint: Stand in front of the mirror and raise your arms. If your skin shows, the top is too short). Cleavage should not be visible when sitting up straight or leaning forward. Slacks or skirt should be modest. Skirts shorter than the top of the patella should not be worn to clinical. Remember that clinical practice is active and may require standing, stretching, and bending over. Hair should be well groomed and pulled back and secured if long. Shoes should be appropriate for a day’s standing; and you need to avoid open toes or high heels. Jeans are not appropriate, even if other members of the staff wear them. Professional attire for men is similar. You must have ironed shirts with collars and a tie if the other male providers wear ties. Dress slacks, socks, and shoes are a must. Jeans, sandals, and sneakers are never appropriate even if other providers wear them. A wedding ring or a conservative ring is permissible. A small earring is permissible. No other piercings should be visible, no tongue jewelry. Nails should be well trimmed and not extend over one-quarter inch from the end of the finger. No nail polish is permissible. Men should be clean shaven or may have a neatly trimmed beard/mustache. All students should refrain from using perfume or cologne in the clinical setting. Some patients are sensitive to smells which may exacerbate their condition (i.e., migraines, nausea, etc). You should also be cognizant of your body odor. In some cultures, the use of deodorant may not be common practice, however you should be taking into consideration that your odor may be offensive to patients, much in the same way that perfumes or colognes can be. Use of deodorant by students in the clinical setting is strongly recommended. All forms of class assignments and/or discussion are to be free of any and all information that could potentially lead back to the identification of a patient or patient situation. Although we recognize the value of dialogue surrounding circumstances that present as unique and perhaps can be seen as relevant for teachable moments, protecting patient information takes precedence. For the purpose of learning and improving care, potentially identifiable information should be masked so that all parties are protected. Violations of patient confidentiality will be handled by the Professional Misconduct Committee within the college and according to agency policies wherein the violation has occurred. Cellphone calls and texts are not allowed in the clinical setting except in the case of an emergency. Cellphone ringers and text notifications should be muted upon entering the workplace. If you must make a call, it should be done on a designated break or lunch hour. Remember that you are a guest in the facility and you represent Chamberlain University. The use of social networking, although common in our lives outside of our professional roles, is associated with significant risk of violating patient privacy when professional matters are discussed on social networking sites. Even if patient names are not used, patients and facilities may still be identifiable to other persons reading the post. It is never appropriate to contact a patient through social media. Now let’s talk about clinical preceptors. You may only use preceptors that have been approved by faculty through the vetting process in your practicum application. So, if your original preceptor is not available but another provider in the office is willing to take you on, this preceptor has to be approved just like your original preceptor was before he/she can be used. Any hours that are spent with a preceptor that has not been approved will not count, so it is advisable that you have at least one back-up preceptor documented with Chamberlain and approved for each clinical practicum in case your first preceptor becomes ill or is out unexpectedly. Other things you have to know, well, you are not allowed to follow a preceptor in the office and if you do you cannot count any of this time towards your clinical hours. You are to be actively evaluating patients and developing a plan. On the first day in the office is it acceptable to shadow your preceptor in order to gain a grasp of office procedures and the flow of patients but again you can only count the clinical time with the patients that you have participated care with. So if you are shadowing for the full day, you can’t count those hours. Beyond that, you should be researching the patient’s chart, performing a history and physical (H&P) and any of that process or any of the work-up can be documented as part of your clinical time. In the first part of the course, you will need some help in developing the differential and coming up with a treatment plan; however, as the course progresses and you become more confident, you should be able to need less of your preceptor’s input. You should never see patients on your own. The preceptor must always have some level of input or review of their patients you see because they are ultimately responsible for the patient’s care. Communicate with your preceptors. Remember that you are a guest in the preceptor’s office, and these are not your patients; be considerate, observe office policies, be respectful to all of the staff, and don't argue. Additionally, it’s never a good idea to point out to a preceptor that their method or practice is incorrect from what you have been taught. You also want to discuss your clinical goals on day one with your preceptor. Verbalize that this is your first clinical in the program and that you realize there is a lot to learn. Admit that you are just starting to formulate differentials and develop EBM treatment plans in class. Although you may lack knowledge and experience in the beginning, you should be showing progress week to week in becoming more independent. Finally, let’s discuss presenting a patient to your preceptor or instructor. By now, you should have a solid understanding of the components of a visit, which are the history and physical, differential diagnoses, and plan. Although this might be easy to do on paper, most novice students find it difficult to present this information in an organized and concise manner to their preceptor or instructor. So, I am going to share with you a technique called SNAPPS. SNAPPS is a pneumonic that breaks down your patient presentation into six parts. The first part, the S in SNAPPS, stands for summarize. This is where you present your patient’s history and physical exam findings. The N stands for narrow, and that’s where you narrow your differential down. So, essentially based on the history and exam findings, you find your top two or three differential diagnoses. A stands for analyze, and this is where you analyze the differential. At this point, you compare and contrast the history and physical exam findings for each of the differentials that you have, ultimately coming down to one most likely diagnosis based on your data. The next part is the P, which stands for probe. This is where you can ask the preceptor questions about things that you aren’t quite sure about. The last P in SNAPPS stands for plan. This is where you will come up with a management plan, being as specific as possible. Finally, the S in SNAPPS stands for self-directed learning. So, this is your opportunity to investigate more about the topics you are still a little unsure about. You will be expected to present you’re a patient in the SNAPPS format during clinical and in the SNAPPS assignments during this course. To help you gain a clearer picture of the SNAPPS presentations, please view the 2 video lectures on the SNAPPS. WEEK 2 NAUSEA, VOMITING, & DIARRHEA When a patient presents to the primary care setting with complaints of acute onset of nausea, and vomiting, a thorough history will be key to forming your differentials. You will find that a bit of detective work is necessary, and the circumstances surrounding the episode or episodes can give helpful clues to the cause. Nausea and vomiting can stem from different conditions in several body system. Gastritis associated with alcohol consumption or drugs such as NSAIDs, aspirin, antibiotics, and illicit substances are also a common cause of acute nausea and vomiting in adults. Nausea and vomiting are listed as adverse effects of many prescription drugs but can also be the presenting symptom for many diseases such as hepatitis, myocardial infarction, and peptic ulcers. However, the most common cause of nausea and vomiting in adults and children is acute gastroenteritis and we’ll call this AGE. This is what we will focus on in this lecture. Be sure to look at Chapter 11 in your textbook which discusses some of the other causes of nausea and vomiting. Acute Gastroenteritis (AGE) is essentially an inflammation of the stomach and intestine. When inflammation of the stomach is predominant, nausea and vomiting are prominent symptoms. When the intestines are most affected, abdominal cramps and diarrhea dominate the picture. However, it is not uncommon for patients to present a framework with extensive inflammation, suffering from vomiting and diarrhea at the same time. Pathophysiological causes of AGE are numerous, however viral, bacterial, and parasitic are the most common with viral being the most likely. We will discuss some of these pathogens in greater detail shortly. AGE is characterized by a rapid onset that lasts less than 2 weeks and may be accompanied by varying degrees of nausea, vomiting, fever, diarrhea, or abdominal pain. Both vomiting and diarrhea are usually present, but either can occur alone with AGE. Symptoms depend on the underlying cause but may also include fatigue, malaise, anorexia, tenesmus, and borborygmus. A careful history provides clues as to the causative agent and the suspected vector of transmission. So you will want to ask your symptomatic patients if they have recently eaten any raw or undercooked food (sushi), traveled out of the country, or had any sick contacts. An antibiotic history should also be assessed. The duration of the illness is important in the DDx because acute diarrhea is usually caused by infectious agents, whereas chronic diarrhea usually has a non-infectious etiology. The physical exam is usually normal except for the aforementioned GI problems. Depending upon the degree of dehydration, mucous membranes may be dry and vital signs may reveal tachycardia and orthostatic hypotension and/or dizziness. Viral gastroenteritis can be caused by several viruses. Norovirus is the leading cause of acute diarrhea for adults, whereas rotovirus is the leading cause of gastroenteritis for the pediatric population, especially for children up to 2 years of age. However, the incidence of rotovirus in children has fallen significantly since the introduction of the rotovirus vaccine. It is possible for adults to have a rotovirus infection, but generally it is less common and clinically milder in presentation. Other rarer viral etiologies include CMV and HSV and they tend to occur more often in immunocompromised patients. So, if you suspect AGE, what testing is indicated? Stool studies are not typically indicated for nonbloody diarrhea and no evidence of systemic toxicity. In the otherwise healthy adult, the disease will normally run its course without incident, and there is no need for extensive testing. Selection of the most appropriate tests is based on information received from the history and physical exam. If a patient appears to have signs of dehydration, serum electrolytes including sodium, potassium, and creatinine should be measured. Ordering a complete blood count does not help to distinguish between viral and bacterial gastroenteritis and may or may not be elevated in the presence of AGE. Stool studies are indicated for patients with severe or prolonged diarrhea, and stools should be examined for consistency, blood, and fecal leukocytes. Stool cultures should be performed on any patient with severe diarrhea, a fever of 38.5 C, bloody stools, or stools that test positive for leukocytes or occult blood because these symptoms are indicative of diffuse colonic inflammation, likely from a bacterial pathogen. When ordering stool studies, you need to check with your local laboratory for specific ordering instructions and identification of correct collection tubes. You only want the patient to have to do this once. If your office does not have the testing capacity to examine stool for leukocytes directly, a sample should be sent to the lab to test for WBCs and blood. In most labs, routine stool cultures will identify the presence of Shigella, Salmonella, Campylobacter, Aeromonas, Yersinia, and certain types of E. coli. A separate test, ova and parasites (O&P), should be performed to identify Giardia and Cryptosporidium, which are not reported as part of a routine culture. If you have a patient who recently traveled out of the country and presents with acute onset of nausea, vomiting, and diarrhea, you should consider traveler's diarrhea. Common pathogens responsible for traveler's diarrhea are usually bacterial and include Shigella, Campylobacter, and E. coli. In patients with epidemiological evidence, stool samples should be sent to the lab for routine culture and specific enteropathogen studies that are not normally detected with routine stool culture such as enterohemorrhagic colitis (E. coli O157:H7) and Vibrio cholerae. Finally, any patient who develops diarrhea after initiation or completion of antibiotic therapy should have tissue culture assay or ELISA test for C. difficile toxin. The DDx of acute gastroenteritis, particularly in patient with persistent or chronic diarrhea and severe abdominal pain, should include IBS; IBD such as Crohn’s or Ulcerative Colitis; ischemic bowel disease; partial bowel obstruction; small bowel diverticulosis; and chronic pancreatitis, to name a few. Although most cases of AGE can be treated on an outpatient basis, you should be aware of "red flag" symptoms that identify patients who may need hospitalization or evaluation for other causes. These include severe volume depletion, dehydration, abnormal electrolytes or renal function, bloody stool/rectal bleeding, weight loss, severe abdominal pain, prolonged symptoms greater than 1 week, hospitalization or antibiotic use in the past 3–6 months, pregnancy, or advanced age. How do we treat AGE? AGE is usually self-limiting and resolves within a week after onset of symptoms. Treatment should consist of supportive measures including fluid repletion and nutrition. There is no evidence that a BRAT or low-residue diet (i.e., bananas, rice, applesauce, toast) hastens recovery time with AGE, however if it is easier for patients to tolerate, so it can be helpful. Fluid repletion in those who are demonstrating mild to moderate dehydration, oral rehydration solutions such as pedialyte can be more effective than sports drinks in maintaining electrolyte balance and hydration. If you suspect severe dehydration (clinical signs include tachycardia, hypotension, pallor, poor skin turgor), IV fluids are usually necessary and warrant an ER referral. There is a widespread misconception among the public that antibiotics are the cure all for any kind of illness including viral gastroenteritis. We need to reassure patients that acute gastroenteritis is almost always viral and in most cases is self-limiting. Prescribing antibiotics for a viral illness only increases antibiotic resistance and puts people at risk for contracting conditions such as C. diff. However, empiric antimicrobial therapy is recommended for patients with severe diarrhea suspected from traveling. Trimethoprim-sulfamethoxazole or Bactrim DS at 1 tab BID × 3d is effective. Other antibiotics that are effective for milder forms of illness include ciprofloxacin (Cipro) 500 mg, norfloxacin (Noroxin) 400 mg, or ofloxacin (Floxin) 300 mg. Antibiotic prophylaxsis for patients traveling to high-risk areas is about 90% effective. Treatment of one of the aforementioned antibiotics should be given in daily doses continuing until 2 days after returning home. In the population under 65 years of age, you can consider a 1–2-day course of loperamide (aka immodium) in those patients with moderate to severe diarrhea. If patients have any risk factors for C. diff (recent antibiotics, hospitalizations, or hospital workers), you should first perform a stool test for C. diff prior to prescribing loperamide. You can also consider a 1–2-day course of zofran or phenergan for those with significant vomiting. Other commonly prescribed drugs for symptomatic treatment of diarrhea can be seen on the table on page 536 of your textbook. The aim of patient education is prevention of the spread of disease. Proper handwashing is the best way to do this! Any infant or child with infectious diarrhea should not attend daycare until the diarrhea has stopped. Finally, patients traveling to high risk areas should be instructed to consume only safe foods and beverages. ABDOMINAL PAIN DUE TO BOWEL DISORDERS In today's lecture, we will be discussing abdominal pain caused by bowel disorders. These are complaints that often present to the primary care provider as the first point of contact. Specifically, we will examine the differences between Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS) and consider the diagnoses of constipation and diverticulitis. We will examine the presentation of these diseases from history and physical, making the diagnosis, diagnostic testing, and standard treatments. This lecture corresponds with Chapter 11 in your textbook, which should be reviewed prior to this presentation. In terms of forming a differential diagnosis for a patient that presents with abdominal pain, it is important to start by isolating the location of the pain. That being said, remember that the abdomen is a poor historian. In other words, there are no hard and fast rules on location of abdominal pain and correlation with specific conditions. So, here we have a chart that looks at some of the common conditions that correlate with specific quadrants of the abdomen. Pain in the LUQ of the abdomen can be caused by stomach ulcers, pancreatitis, and gastritis. RUQ pain can be caused by problems with the gallbladder, hepatitis, or pancreatitis. RLQ pain can be associated with IBD, IBS, infectious colitis, and constipation. LLQ pain can be associated with diverticulitis, IBS, IBD, constipation, and infectious colitis. We’ll go over differential diagnosis of abdominal pain in more detail after talking about some common bowel disorder. Okay, so let's now take a closer look at IBD and IBS. IBS, or irritable bowel syndrome, is a disorder of bowel function (as opposed to being due to an anatomic abnormality). Patients who suffer from irritable bowel syndrome have changes in bowel habits, such as constipation or diarrhea, and abdominal pain along with other symptoms including abdomin