Archive for the ‘nurse writing’ Category

Understanding the importance of ICD-10 to nursing

U.S. healthcare organizations will soon begin using ICD-10 diagnoses and procedure codes to report to Medicare, making the switch from ICD-9 procedure codes in October 2014. Nursing students are not normally interested in the details of such reporting but becoming familiar with this new coding scheme may prepare you for the richness of data that will be available and useful to researchers.

There are many thousands of ICD-10 codes but each code consists of only seven or fewer characters. The position of the character within the code defines the meaning of the code. LetΓÇÖs look at an example: accidental injury caused by chickens and turkeys. While such injuries are probably not common in an urban setting this example does serve as a fun, easy to understand illustration of the detail available within the codes.

Consider the following ICD-10 diagnoses codes:

  • W6132XA Struck by chicken, initial encounter
  • W6132XD Struck by chicken, subsequent encounter
  • W6132XS Struck by chicken, sequela
  • W6142XA Struck by turkey, initial encounter
  • W6142XD Struck by turkey, subsequent encounter
  • W6142XS Struck by turkey, sequela

The first three characters are part of a chapter: External causes of morbidity (V00-Y99). That is, W61 falls within the range of V00 to Y99.

Within the chapter are subsets of codes called blocks. In this example, the block is: Other external causes of accidental injury (W00-X58). Again, W61 falls within this range.

Within the block is a category. In this example W61 is the category: Contact with birds (domestic) (wild).

The next three characters are the specific diagnosis. 32 is struck by chicken, 42 is struck by a turkey. X is a place holder used when there is no need for a digit in that position.

The last character is an extension; it further delineates the diagnoses.

  • A = initial encounter
  • D = subsequent encounter
  • S = sequel

Encounters are with healthcare providers, not chickens or turkeys. For example ΓÇ£Struck by chicken, subsequent encounterΓÇ¥ is used when the patient returns for follow-up. ΓÇ£Struck by chicken, sequelaΓÇ¥ is a condition directly related to the initial injury, for example, a scar related to the initial injury.

A nurse in an urban setting would rarely see such injuries. But these examples illustrate the rich level of specificity that will be available in coded data. How many patients are you seeing with injuries related to chickens and turkeys? How many follow-up appointments do these patients need? What are the nursing interventions and teaching materials you will need to care for these patients? Are turkey-related diagnoses seasonal in nature?

There are many, many ICD-10 diagnoses codes; undoubtedly your area of expertise will be reflected in the codes. You can dig through CMSΓÇÖs web site to find the codes or find a link to all of the codes directly on our website at http://www.referencepointsoftware.com/miscfiles/ICD10CM_FY2014_Full_PDF_Tabular.zip

Reference:
Centers for Disease Control and Prevention (2014). International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Retrieved November 18, 2013, from http://http://www.cdc.gov/

David Plaut, MS is the founder of Reference Point Software (RPS). RPS offers a complete suite of easy-to-use formatting template products featuring MLA and APA style templates, freeing up time to focus on substance while ensuring formatting accuracy. 

 

For more information about MLA or APA writing templates, contact us by email

Receive Top Marks on Your Nursing Papers by Avoiding These 4 Common Writing Mistakes

Being a nursing student comes with responsibilities that students in other disciplines simply donΓÇÖt have. You have to work long hours while making time to fit in studying along with clinical work. You may have family responsibilities to juggle, too. With all of these demands, itΓÇÖs likely you may feel stressed and tired often. This can make writing nursing papers, another factor in your student life, very challenging.

Your papers must contain the same precision that is expected of your clinical work. You are expected to show evidence of thorough reading and the accurate recording of the facts and ideas and you need to include your own viewpoint in a concise manner. However, little sleep and high stress can cloud your ability to always do your best writing. Here are some mistakes that nursing students make when writing papers that you need to avoid if you want to earn top marks.

1. Wordiness and Repetition

Wordiness and repetition are by far the biggest mistakes students make with their papers. ItΓÇÖs not the quantity of the words you write that matters, but whether what you write has meaningful content. Some typical examples of wordiness and how they can be improved are:

Due to the fact that – because
At that point in time – then
In the process of – during, while
Regardless of the fact that ΓÇô although
In the event that – if

A good way to check for wordiness and redundancy is to read your work aloud and think about how it sounds. Are you using too many words to say what you mean or including different words to say the same thing more than once? You need to master the ability to be brief but comprehensive, saying what you need to say clearly in as few words as possible.

2. Vague and Imprecise Language

A nurseΓÇÖs writing has to be clear and precise, both to facilitate quality care and to inform physicians, other nurses and the recipients of your care. As a student nurse, you will be required to demonstrate that ability by clearly writing your observations and leading readers convincingly to your conclusion. There is no room for vague, imprecise language. Your paper must contain precise nouns and verbs and any vocabulary specific to the field of nursing that youΓÇÖre studying.

3. Clichés

Clichés have no place in any academic paper. That goes doubly in nursing papers! If you find yourself tempted to use expressions such as “time will tell”, “the writing is on the wall”, or “up in the air”, they will cost you points on your papers. While some phrases may seem clever to you, that won’t have the same impact on your readers. Clichés are often overused, and can have hidden meanings, as well as possibly being untrue. They will diminish the quality of your paper.

4. Excessive Digression

DonΓÇÖt let your writing wander off the point. While there are some deviations that serve a legitimate purpose in your paper, like an anecdote to further engage your reader, they still need to tie back in to your primary point. Read your work carefully and be ruthless in editing out anything that isnΓÇÖt relevant.

Ultimately, your nursing papers must be focused and fact based. In addition to concise writing, you will include references from other authors and data sources for credibility. You need to cite your references accurately using the correct formatting style. Nursing papers are usually written using the APA style. You can learn how to use the APA formatting style and hope you donΓÇÖt make mistakes. However, with all of the pressures and demands on your time that come with being a nursing student, you may prefer to use formatting software. With a click of a button you can save yourself time and be sure that your formatting complies with the latest APA standards.

David Plaut is the founder of Reference Point Software (RPS). RPS offers a complete suite of easy-to-use formatting template products featuring MLA and APA style templates, freeing up time to focus on substance while ensuring formatting accuracy. For more information, log onto http://www.referencepointsoftware.com/ or write to:
info @ referencepointsoftware.com

Reference Point Software is not associated with, endorsed by, or affiliated with the American Psychological Association (APA) or with the Modern Language Association (MLA).

How to Write a Case Study Paper for Nursing

A well-written case study paper for a nursing program requires some planning and consideration. All too often, students begin writing before they complete appropriate, preliminary steps. Ideally, before you start a paper, you should already have determined the focus and format of it. You will then follow this up with a fact-gathering step in which you will gather and collate the content of your paper. Finally, there is the construction/execution step in which you will write the paper in a standard format (such as the APA style) and edit it.

A nursing case study paper contains several sections that fall into three categories:

1. The status of the patient

2. The nursing assessment of the patient

3. Current Care Plan and Recommendations

  • Details of the nursing care plan (including nursing goals and interventions)
  • Evaluation of the current care plan
  • Recommendations for changes in the current care plan

Patient Status

The first portion of the case study paper will talk about the patient — who they are, why they are being included in the study, their demographic data (i.e., age, race), the reason(s) they sought medical attention and the subsequent diagnosis. It will also discuss the role that nursing plays in the care of this patient.

Next, thoroughly discuss any disease process. Make sure you outline causes, symptoms, observations, and how preferred treatments can affect nursing care. Also, describe the history and progression of the disease. Some important questions for you to answer are: 1) What were the first indications that there was something wrong, and 2) What symptoms convinced the patient to seek help?

Nursing Assessment

When you are discussing the nursing assessment of the patient, describe the patientΓÇÖs problems in terms of nursing diagnoses. Be specific as to why you have identified a particular diagnosis. For example, is frequent urination causing an alteration in the patientΓÇÖs sleep patterns? The nursing diagnoses you identify in your assessment will help form the nursing care plan.

Current Care Plan and Recommendations for Improvement

Describe the nursing care plan and goals, and explain how the nursing care plan improves the quality of the patientΓÇÖs life. What positive changes does the nursing care plan hope to achieve in the patientΓÇÖs life? How will the care plan be executed? Who will be responsible for the delivery of the care plan? What measurable goals will they track to determine the success of the plan?

The final discussion should be your personal recommendations. Based on the current status of the patient, the diagnosis, prognosis, and the nursing care plan, what other actions do you recommend can be taken to improve the patientΓÇÖs chances of recovery? You must support your recommendations with authoritative sources and cite appropriately per APA style guidelines.

Creating a well-written nursing case study paper doesnΓÇÖt need to be a grueling challenge. It can be gratifying, and itΓÇÖs good practice for assessing patients while out in the field, too. Keep in mind that your instructor will not only grade you on the quality of the content of your paper but by how you apply the APA style, as well. If you find that you are spending too much time formatting your paper, consider using formatting software as a helpful tool to ensure accuracy, so you donΓÇÖt lose points on a well-written paper because of some formatting errors.

 

For more information about APA or MLA formats, contact us today.

David Plaut is the founder of Reference Point Software (RPS). RPS offers a complete suite of easy-to-use formatting template products featuring MLA and APA style templates, freeing up time to focus on substance while ensuring formatting accuracy. 

Reference Point Software is not associated with, endorsed by, or affiliated with the American Psychological Association (APA) or with the Modern Language Association (MLA).