Step 1: Case of Jane Black: See information on below for case study information

- Female, 32 years of age/ Married with 3 children/ 22 weeks pregnant/ Newly diagnosed Diabetic/ right-sided weakness

PMH- Right-sided weakness from a "minor stroke" 5 years ago

Mother of 3 children aged 7, 5, 3

Hx of present illness: - Newly diagnosed Diabetic

22 weeks pregnant (4th pregnancy)

Experiences polydipsia and polyuria

Found at home drowsy and having difficulty focusing

Family Hx

Mother is diabetic with vision problems and recently diagnosed with kidney failure

7 y/o daughter has Cystic Fibrosis

Husband smokes and is overweight

Living Conditions:

Renting a 3 bedroom apartment

Primary family caregiver

questions

1 What Interprofessional team members would you include for this client?

2 What would the nurse document in this case situation

3 What do you see as the issues and challenges of interprofessional documentation?

4 What strategies can you come up with to overcome the issues an challenges of interprofessional documentation?

 

1. What Interprofessional team members would you include for this client?

These will include:

A. Diabetologist

B. Endocrinologist

C. Nephrologist

D. Obstetrician

E. Neurologist

F. Physician

2 What would the nurse document in this case situation?

The nurse will document :

A. The personal details of the patient.

B. Detailed history of the patient

C. Past medical history

D. Medications history

E. Social history and family history

F. Patient's vital signs.

G. Patient's general examination parameters like pallor, dehydration et cetera

H. Fluid input and output.

I. Patient's musculoskeletal exam findings.

J. Obstetric ultrasounds findings

K. Patient's random and fasting blood sugar findings.

L. Patient's assessment of level of consciousness using the Glasgow coma scale.

M. Antenatal care history and findings.

3. What do you see as the issues and challenges of interprofessional documentation?

They include the following:

A. Lack of a clearly stated, shared, and measurable purpose because of different and conflicting goals and desired outcomes making documentation difficult

B. Lack of training in interprofessional collaboration role and leadership ambiguity disrupting harmony in documentation.

C. Team being too large or too small making the input of individual professionals either inadequate or overwhelming and confusing.

D. Team not composed of appropriate professionals creating conflicting documentation directives which could harm the patient

E. Lack of appropriate mechanism for timely exchange of information which can hinder the smooth management and documentation of the patient findings and orders or directives.

F. Team members being accustomed to assuming total responsibility creating interteam conflict.

G. Team members having unease with allowing others to be involved in clinical decision-making with each team members wanting their own management and findings to be documented.

H. Discomfort with performance review by team members of different professional

backgrounds

I. Legal liability for others' decisions and dilution of traditional one-to-one relationship with patient/client.

4 What strategies can you come up with to overcome the issues an challenges of interprofessional documentation?

These may include:

A. Making the Interprofessional team to come up with protocols and guidelines which can be applied uniformly by all members despite their fields of specialty.

B. The team updating each other in weekly or daily meetings on the progress of the patient and the interventions each of them have instituted so that they can be at par with their decisions.

C. The team can see the patient together at specific days so that what is documented is uniform.

D. Agree on unifying philosophy centered around primary care of the patient/client and the

community.

E. Developing a commitment to the common goal of collaboration

F. Each team member learning about other professions to understand their way of thinking and try to incorporate it in their management and decisions they make for documentation.

G. Respecting others' skills and knowledge and input and avoiding overruling each other's documentation.

H. Establishing positive attitudes about own profession;

I. Developing and establishing trust between members so that each member can trust and have faith in what another member has, instructed to be documented.

J. Team members being willing to share responsibility for patient/client care.

K. Establish a mechanism for negotiation and re-negotiation of goals and roles over time and consulting each other before documenting findings of the patient.

L. Establishing method for resolving conflicts between team members and be willing to work continuously on overcoming barriers including avoiding tarnishing the name and reputation of one's colleagues as this, can influence the attitude of the nurse documenting finding of the patient on another professional in the team.