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•The nurse does not yet know that patient has not been taking his medication for the last two weeks, or that he had an adverse reaction to Prozac resulting in manic outbursts, self-injurious, and aggressive behaviors during an inpatient psychiatric hospitalization two years prior.
EXAMINING THE DATAHow can data be accessed & collected? •Electronic Medical Record•Pharmacy Records •Primary Care Provider Records (if they are not utilizing the same electronic medical record) •Nurse to Nurse verbal report prior to patient transfer •Verbal report of the patient & accompanying family if applicableWhat information can be obtained ? •Prior medical & psychiatric history •Including past hospitalizations & Emergency Room Evaluations •Prescribed medications (Inpatient & Outpatient)•Currently & Previously Prescribed Medications •Clinical rationale for any possible alterations in medication regimen •Prior response to treatment & Level of engagement •Prior personal interactions with peers & staff •Risk Profile History •Examples: Self-Injury, Aggression, Suicidal Ideation, Elopement Risk
HOW CAN THIS OBTAINED KNOWLEDGE BE IMPLEMENTED INTO PATIENT CARE? Prior to AdmissionThe nurse will collect the available knowledge from the electronic medical record, previous providers, and the pharmacy to develop an educated plan of care for her future patient. Learning that the