Patient Logs Paper

Patient Logs Paper

Patient Logs Paper

During the week of (date), I interacted with patients suffering from diverse conditions. These interactions were essential in helping me gain valuable insights into patient care and the challenges faced in delivering comprehensive care to patients. The following log summarizes the assessment findings, diagnoses, care plans, and interpersonal reactions with the patients.

Patient Assessment

Patient A

He was a middle-aged man in his 30s who presented with symptoms of loss of interest in pleasurable activities, persistent sadness, and disturbances with sleep. His past health history revealed that he had undergone recent stressful events and a profound history of depression in his family. His symptoms were consistent with a diagnosis of major depressive disorder since he also had thoughts of harming himself, anhedonia, and feelings of worthlessness. The differential diagnoses were adjustment disorder and dysthymia. His treatment plan included Cognitive Behavior Therapy as the primary intervention to help promote positive coping strategies and address his negative thought patterns. Administration of antidepressant medication, especially selective serotonin reuptake inhibitors (SSRIs), was also considered.

Given the severity of his symptoms indicative of depression and the high risk of harming himself, I recommended an immediate visit to the psychiatrist for medication initiation and further evaluation. This would be followed by regular follow-up visits to assess the response to medication and adjustment of medication dosage accordingly.

Patient B

This adolescent presented irritability, difficulties in concentration, and withdrawal from social activities; he also had a history of bullying at school. His symptoms indicated adjustment disorder, supported by his impaired performance in school, low self-esteem, depressed mood, and excessive worry. The differential diagnoses were major depressive disorder and generalized anxiety disorder. The treatment plan included supportive therapy that would help the client with coping skills to manage the impact of bullying and address self-esteem issues. Working with the school to help prevent further bullying was also essential.

The patient’s symptoms are related to a specific stressor, bullying. The appropriate interventions are working with the client through supportive therapy and involvement of the school personnel in helping to prevent further bullying. The patient would also be checked regularly to check on how they are doing and monitor their academic progress regularly. I provided psychoeducation to the patient and emphasized the essence of reducing stress, validating their emotions, and providing reassurance.

Interpersonal reaction Recording

While interacting with the patients, I listened actively to them, reassured them, and validated their emotions. In particular, patient B seemed relieved to have an open space to share his emotions without fear of being judged. Witnessing the patient’s gradual transformation was rewarding and enhanced the value of therapeutic relationships in facilitating growth and healing.

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Clinical objectives

The week’s objective was to conduct a detailed assessment of the patients, reach accurate diagnoses, develop effective management plans, and demonstrate professionalism throughout my interactions with them. My objectives were met. I performed thorough patient assessments, developed primary and differential diagnoses, and formed appropriate care plans based on the standard guidelines. Despite being successful, time constraints hampered the depth of my evaluations. To overcome this hurdle, it will be essential to prioritize time management and seek opportunities to enhance my efficiency.

Personal practice and feelings

Through the provision of patient-centered care, I experienced a sense of fulfillment in establishing effective therapeutic relationships and applying skills and knowledge to help enhance the well-being of the patients. There were challenges in making critical decisions and management of complex cases, which would potentially delay offering patients timely interventions. I recognized the essence of mitigating potential adverse outcomes and ensuring that the patients were always safe.

Strengths in professional practice

My ability to establish rapport and create a safe space for patients to share their information with me was one of the strengths I identified. I listened actively to the patients, utilized effective communication skills to forge therapeutic alliances, and displayed empathy with the patients. For instance, patient B’s expression of relief and openness implied that the relationship formed with them was supportive.

Areas for improvement

My time management skills require improvement. In some instances, I felt like I could not go deeper into the history of the patients; it was like I was rushing. This can hamper achieving accurate diagnoses and reaching comprehensive care plans. I also recognized the essence of improving proficiency in the coordination of care among diverse healthcare providers to ensure that interventions are timely and there is a seamless transition of care.

Strategies for improvement

I will set realistic expectations, goals, and deadlines, prioritize tasks and use electronic resources to help with documentation. I will also engage experienced colleagues to help me with time management and care coordination skills. Attending pertinent seminars and workshops on professional development will help my knowledge grow and improve my management skills.

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2. The logs should be done in 7th edition APA format with a cover page and be approximately 2-3 pages (minus the cover page). Please remember to use complete sentences.

3. The log should contain patient assessments and discussion of the following issues (omitting names of facilities and people):

Date and times of each clinical experience during the time frame.

Types of patients seen.

Your comprehensive patient assessment should include:

â–ª History, Mental Health Assessment, Diagnosis, Treatment Plan, disposition and rationale for each diagnosis (include differential diagnosis(es)) and treatment selected or that you would recommend.

â–ª Any treatment/intervention given.

â–ª Interpersonal Reaction Recordings for at least one client.

Suggestions for Self-Evaluation of Logs:

1. State your clinical objectives for the week. Were your objectives met? If so how? If not, why? Use your written clinical objectives as a guide.

2. Discuss feelings that relate to your professional practice this week? Include at least one aspect of professional practice as an NP and one aspect of case management, risk management.

3. What aspects of your professional practice do you identify as strengths?

Give specific examples that support your conclusions.

4. What aspects of your professional practice do you identify as needing

improvement?

Give specific examples to support your conclusions.

5. What strategies will you use to improve this/these aspects of your practice?

When, where and how will you implement your strategies for improvement.

this has to be related to spych NP, my clinicals is in an emergency room, seeing spych patients

you have have any example i dont mind