Evaluate patient needs based on age, developmental stage, family history, eth- nicity, and individual risk, including genetic profi le, to formulate plans for health promotion, anticipatory guidance, counseling, and disease prevention services for healthy or sick patients and their families in any clinical setting.
PO 1A. Identify a potential genetic risk.
PO 1B. Diagnose a genetic condition.
PO 1C. Evaluate individual patient needs based on age, developmental stage, family history, ethnicity, and individual risk.
PO 1D. Formulate a plan that addresses health promotion, anticipatory guidance, and/or disease prevention for the individual.
Chapter 4 Clinical Case Narrative Writing
41
Summary of Care (provided prior to case narrative)
This note is written when the DNP resident assumes care for a patient known to a practice or addresses care prior to the time period that is the focus of the case narrative. For each identifi ed active problem, a brief summary describes the patient care to date and the response to treatment. The following points should be included: initial diagnosis (time of diagnosis), relevant clinical fi nd- ings, diagnostic tests, interventions, patient response to most recent therapeu- tic intervention, and proposed plan. The summary of care note precedes the encounter context.
Example: The patient is a 24-year-old white female who has been seen in the Multiple Sclerosis Center for approximately 20 months. She was referred by an ophthalmologist for evaluation of optic neuritis (ON). After a complete diagnostic evaluation that included MRI of the brain, cerebrospinal fl uid examination, serum review, and neurological exam, she was diagnosed with multiple sclerosis (MS) and initiated on long-term injectable treatment, interferon beta-1a (Avonex).
While on treatment she continued to have relapses, including sensory, motor, and visual disturbances. She was treated with intravenous steroids for these relapses with benefi t to her symptoms. She had reported mild depression and anxiety, especially regarding her diagnosis and “dealing with symptoms,”
as well as increased fatigue. She was started on fl uoxetine (Prozac) 10 mg daily and was referred to a social worker at her last appointment. She was scheduled for today’s appointment as a routine follow-up.
Encounter Context
The case narrative begins with the encounter context. This includes informa- tion to orient the reader to the initial encounter with regard to setting, time, context, patient demographics, and DNP role.
Example
Encounter Context
Encounter One (initial evaluation)
DNP role: I am an adult nurse practitioner and DNP resident seeing this patient for an initial consult visit.
Identifying Information
Site: Urban academic medical center.
Setting: Movement disorder specialty private offi ce practice.
Reason for encounter: Initial evaluation, referral note on prescription pad from community physician.
Informant: Patient and home attendant. The home attendant has worked with this patient for three days. The home attendant has a referral note from a community physician that states “evaluate and treat patient for memory loss, mood changes, and leg movements.” No other medical records are available.
Example
Encounter Context
Encounter One (postoperative day 0)
DNP role: I am an acute care nurse practitioner and DNP resident assuming responsibility of care for this patient.
Identifying information
Site: Urban academic medical center.
Setting: Adult surgical intensive care unit (SICU).
Reason for encounter: Patient admission to the SICU.
Informant: Chart review and surgical team report, as patient is mechanically ventilated and sedated following mitral valve replacement.
Patient Encounter or Encounters
This section forms the body of the narrative. The parts of each encounter vary depending on when the narrative begins. Some narratives begin with an initial comprehensive patient encounter. Other narratives begin with a focused or interval note that builds from the Summary of the Care provided prior to the case narrative, described previously.
Distinct templates are provided in subsequent documents to assist in iden- tifying salient aspects of care that are usuallyaddressed in the different types of encounters, populations, and settings.
All encounters are written in the present tense. Most encounters include some or all of the following information:
Chief complaint (in patient’s own words or from other source if patient is
•
nonresponsive)
History of present illness, which includes a relevant review of systems with
•
pertinent positive and negative associated symptoms and risk factors for the presenting complaint
Current health status, which includes active medical problems being treated
•
that are not related to the presenting complaint Past health history
•
Social history
•
Family history, which may include a genogram
•
Review of systems (not related to chief complaint)
•
Physical examination
•
Chapter 4 Clinical Case Narrative Writing
43
Laboratory data review
•
Impression
•
New or undifferentiated problems –
For each new or undifferentiated problem or symptom, create a compre-
■
hensive list of possible diagnoses in paragraph form from most to least likely diagnosis based on the patient’s history, which includes the pres- ence and absence of pertinent fi ndings, physical examination, diagnostic tests, and risk factors. Determine the probability of each diagnosis. State the most likely diagnosis and provide a rationale for the determination.
This diagnosis and rationale will form the basis of the plan.
Ongoing health care needs –
The status of each ongoing identifi ed health care need is discussed.
■
This assessment will form the basis for the ongoing plan of care.
When a previously identifi ed acute or self-limiting health care need
■
resolves, the problem is declared inactive and removed from the active problem list.
Health maintenance and immunizations should be addressed accord-
■
ing to established guidelines. The patient’s health maintenance needs are addressed at appropriate intervals and included in the plan of care under health maintenance.
Plan: The plan of care may be written in varying formats as dictated by the
•
clinical setting. Each plan should always include the following components.
Diagnostic tests –
Referrals –
Medications –
Counseling and education –
Health care maintenance –
Follow-up –
An ICD9 code for each diagnosis identifi ed in the impression
•
Citing and Leveling the Evidence
After appropriate sections of the case narrative, the scientifi c underpinnings for the clinical decision-making are given in italics. This evidence has usually been published within the past fi ve years.
Sources should include primary sources, meta-analyses, or expert guidelines.
The level of evidence for each source is cited using the Centre for Evidence- Based Medicine (CEBM) guideline: http://www.cebm.net/index.aspx?o=1025.
Example
Recurrent chest pain in the absence of coronary artery disease is a com- mon problem that can lead to the excessive use of medical care. This review suggests a small to moderate benefi t from psychological interventions, par- ticularly those using a cognitive-behavioral framework. Patients with atypical chest pain who had negative coronary angiography were more likely to report more severe and prolonged symptoms than those who had not had the proce- dure (Kisely, Campbell, & Skerritt, 2005).
Oxford Centre for Evidence-Based Medicine (CEBM), level 1a.
Documentation of Performance Objectives
The performance objectives of a competency are met by behaviors that direct the outcome of the case narrative. After appropriate sections in the case nar- rative, the performance objective that was demonstrated by the DNP resident’s actions is stated in bold font. Documentation explicates the DNP resident’s actions, which may be illustrated by education, counseling, treatment interven- tions, referrals, consultations, or clinical decision-making.
Example: The patient has a congenital cardiac malformation, which is deter- mined almost exclusively by genetics. I discuss this information with him and his wife. They state they understand that blood-related family members may wish to discuss this information with their health care providers. (D1, C1, PO A, B).
Critical Appraisal
When appropriate to a section of the case narrative, a detailed discussion of the DNP resident’s thought processes is included as a critical appraisal section in abox.The critical appraisal may be particularly important to an ethical discus- sion or when there is confl icted or ambiguous evidence.
Interim Summary Note
The interim summary note is utilized when the DNP resident does not need to provide detailed information about the care provided at specifi c visits over a period of time. This usually occurs when the patient’s condition is stable and the issues addressed at the specifi c visits are not relevant to the performance objectives and competency that direct the case narrative. For each identifi ed active problem, a brief summary describes the patient care during this intervening period.
Situations such as this can leave health care providers with a delicate ethical dilemma: one between the fundamental ethical principles of autonomy and nonmalefi cence. Autonomy is the patient’s right to self-determination, whereas nonmalefi cence is our responsibility as health care providers to do no harm.
The patient has made his wishes about his care explicitly clear, both in writ- ing and during detailed conversations with his family. Furthermore, although not related to autonomy, his family is in full support of carrying out his wishes given his suffering with previous medical conditions.
Alternatively, health care providers have an ethical responsibility to do no harm to patients. In Western culture, withdrawal of care is considered by many to be giving up or somehow harming the patient. In this situation, the assessments of the neurologist, neurosurgeon, and attending surgeon were unifi ed. There is little hope for recovery that would result in a meaningful life for this patient. The health care team honored the patient’s wishes based on his right to autonomy.
Chapter 4 Clinical Case Narrative Writing
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Example: I saw the patient in my offi ce every two months for the following six months. She lost 10 pounds by following a nutritious, low-sodium diet and increasing her activity by walking to work. Blood pressure control was achieved with enalapril (Vasotec) 5 mg daily. Her blood pressure at the last appointment, one month prior to today’s appointment, was 120/70, and her pulse was 80. She denied any adverse effects from her medications and car- diac symptoms.
Case Summation
This brings the case narrative to its conclusion. This section discusses the out- come of the intervention and the plan for ongoing care, if not discussed in the fi nal encounter.
Example: Stepmother reports that since the last visit three months ago, her child has not had another syncopal episode. He has consciously avoided the neck-stretching movement that preceded the episodes and feels that this has prevented the episodes from reccurring.
Competency Defense
In this fi nal section of the narrative, the DNP resident discusses how each competency was attained. The DNP restates the competency and then critically appraises the care provided and utilizes evidence to demonstrate his or her ability to meet the competency. The defense of each competency is approxi- mately one to two paragraphs in length.
Example
Domain 1, Competency 3. Formulate differential diagnoses and diagnostic strategies and therapeutic interventions with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy for patients who present with new conditions and those with ambiguous or incom- plete data, complex illnesses, comorbid conditions, and multiple diagnoses in all clinical settings.
Defense. The patient’s diagnoses were formulated using the DSM-IV criteria for bipolar I disorder, most recent episode mixed, and polysubstance abuse. Given his presenting symptoms, I identifi ed that a polypharmacologic regimen would be essential to control his symptoms. The available evidence supports the effi cacy of mood stabilization with antipsychotic therapy. Specifi cally, valproate (Depakote) was identifi ed as an appropriate agent for use in the patient with mixed mania and comorbid substance abuse. Similarly, aripiprazole (Abilify) is indicated in the treatment of acute and chronic mixed and manic episodes in patients with bipolar I disorder. Because this patient presents with a history of depressive symptoms, antidepressant therapy must be considered. However, the addition of an antide- pressant must be done with caution due to the risk of causing a switch in mood polarity. Bupropion (Welbutrin) has been associated with a lower risk for mood polarity switch, making it an ideal option for this patient. Although the literature does not consistently support the effi cacy of cognitive behavioral therapy, it was identifi ed as an important component of the treatment regimen.
Additional Documentation
At the end of the case, additional documentation may be provided that is rele- vant to the case but too detailed to include in the body of the narrative because it would distract from the competency focus. Primary among these documents are monograph-style drug lists that include all the medications discussed in the case narrative and that briefl y identify salient indications, pharmacokinetics, and contraindications for the patient. Additional documentation can include pain scales, DSM criteria, validated assessment tools, and institution-specifi c policies and protocols.
Reference Style
Style should follow the Publication Manual of the American Psychological Asso- ciation(APA), 5th edition.
References
American Association of Colleges of Nursing (AACN). (2005).The essentials of doctoral education for advanced nursing practice. Retrieved December 30, 2007, from http://www.aacn.nche.edu/
DNP/pdf/Essentials.pdf
Carraccio, C., & Englander, R. (2004). Evaluating competence using a portfolio: A literature review and web-based application to the ACGME competencies. Teach Learn Med, 16(4), 381–387.
Cook, S.S., Kase, R., Middelton, L., & Monsen, R.B. (2003). Portfolio evaluation for professional competence: Credentialing in genetics for nurses. Journal of Professional Nursing, 19(2), 85–90.
Dannefer, E.F., & Henson, L.C. (2007). The portfolio approach to competency-based assessment at the Cleveland Clinic Lerner College of Medicine. Academic Medicine, 82(5), 493–502.
Gadbury-Amyot, C.C., Kim, J., Palm, R.L., Mills, G.E., Noble, E., & Overman, P.R. (2003). Validity and reliability of portfolio assessment of competency in a baccalaureate dental hygiene program. Journal of Dental Education, 67(9), 991–1002.
Institute of Medicine (IOM). (1996). Primary care: America’s health in a new era. Washington, DC:
National Academies Press.
Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.
Kear, M., & Bear, M. (2007). Using portfolio evaluation for program outcome assessment.
Journal of Nursing Education, 46(3), 109–114. Retrieved January 14, 2008, from Research Library database.
Lim, J.L., Chan, N.F., & Cheong, P.Y. (1998). Experience with portfolio-based learning in family medicine for master of medicine degree. Singapore Medical Journal, 39(12), 543–546.
Melville, C., Rees, M., Brookfi eld, D., & Anderson, J. (2004). Portfolios for assessment of paediatric specialist registrars. Medical Education, 38(10), 1117–1125.
Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W.Y., Cleary, P.D., Friedewald, W.T., Siu, A.L., & Shelanski, M.L. (2000). Primary outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association, 283, 59–68.
National Organization of Nurse Practitioner Faculties (NONPF) National Panel for NP Prac- tice Doctorate Competencies. (2006). Practice doctorate nurse practitioner entry-level competencies. Retrieved December 30, 2007, from http://www.nonpf.com/NONPF2005/
PracticeDoctorateResourceCenter/CompetencyDraftFinalApril2006.pdf
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Utilizing Evidence-
Based Practice in Clinical
Case Narrative Writing
Evidence-based practice (EBP) is the process of identifying the best available evidence to guide patient-centered clinical decisions (Sackett, Straus, Rich- ardson, Rosenberg, & Haynes, 2000). The American Nurses Association (ANA) 2004 Social Policy Statement expressly indicates that one of the six components of contemporary nursing practice is the “application of scientifi c knowledge to the process of diagnosis and treatment through the use of judgment and criti- cal thinking” (American Nurses Association, 2004, 6). However, it has become increasingly diffi cult for individual clinicians to manage the vast amounts of information that are published on an annual basis. Indeed, it is not physically possible to keep current with all new information in one’s domain. For example, Alper and colleagues (2004) estimated that an internal medicine provider would need to read approximately 240 relevant journals, including more than 7,000 journal articles, per month, which could take on average 627.5 hours in that month. Since there are only 720 hours in a month, there is not enough time to examine all possibly relevant information.
According to Cabana et al. (2000), several barriers to guideline use and EBP exist, including lack of awareness, lack of familiarity, lack of agreement, lack of self-effi cacy (the perceived inability to implement new practice or to
5
Leanne M. Currieunderstand the research literature), lack of outcome expectancy (the percep- tion that new practice won’t work), and the inertia of previous practice (it’s too hard to learn a new practice). These barriers likely lead to regional practice variation, whereby some guidelines are implemented but other guidelines are not implemented, often with underserved communities being the ones that have slower guideline adoption rates (Fisher, Bynum, & Skinner, 2009). One of the goals of EBP is to ensure that nationally recommended guidelines are adopted across all settings. This chapter provides an overview of the skills and knowl- edge required to apply evidence to practice in a patient-centered manner.