After reading the chapter in your textbook, focus on documentation and informatics. Think about the principles of reporting and documentation. Identify and briefly discuss three challenges a nurse has in ensuring accurate and confidential documentation. Then discuss what actions a nurse can take to overcome these challenges including how informatics might make a difference. 

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Daniel is a 16 year old boy who is an identical twin. He and his brother Jeff are very close and do most things together. While Daniel excels at sports he believe his brother is much better at most everything. Daniel, his brother, and their two sisters live with their parents in the Midwest. Recently Daniel has been feeling more tired than usual. He thought it was because of his schedule and school work, which he is fairly good at. He gets mostly Bs, but his grades have been slipping of late. One day he fainted while getting ready for a game. His coach called his parents to let them know Daniel was taken to the Emergency Room. While there the doctor decided to admit Daniel to the hospital for observation. At the time he was running a slight fever, his breathing was shallow, and he was sweating. He was also very sleepy and his blood pressure was high. He did have some abnormal laboratory work, but his doctor was not too concerned at present. Daniel also stated that he felt achy.

You are assigned to take care of Daniel today and when you walk into his room, his mother and brother Jeff are there. Daniel appears to be sleeping. In your written assignment, respond to the following questions applying the nursing process:

Assessment: What type of objective and subjective data can you collect with what you know? How will you collect these data? What further evidence do you need?

Analysis and Identification of the Problem: What do you believe Daniel’s problem(s) are? What might be the nursing diagnoses? Use the following for identification.

Planning: Identify two goals and one nursing intervention for each, based on your nursing diagnoses.

While you will not be able to implement or evaluate, how well do you think your nursing interventions might help with Daniel’s care.

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 Key Functions and Competencies  It is anticipated that the initial discussion response should be in the range of 250-300 words. Response posts must demonstrate topic knowledge and scholarly engagement with peers. This is not the only criteria utilized for evaluation; substantive content is imperative. All questions in the topic must be addressed. Please proofread your response carefully for grammar and spelling. Do not upload any attachments. All responses need to be supported by a minimum of one scholarly resource. Journals and websites must be cited appropriately. Citation and reference must adhere to APA format. Classroom Participation  Students are expected to initially address the discussion question by Wednesday of each week. Participation in the discussion forums is expected with a minimum total of three (3) substantive postings (this includes your initial posting and posting to two peers) on three (3) different days per week. Substantive means that you add something new to the discussion, you aren’t just agreeing. This is also a time to ask questions or offer information surrounding the topic addressed by your peers. Personal experience is appropriate for a substantive discussion and should be correlated to the literature.  All discussion boards will be evaluated utilizing rubric criterion inclusive of content, analysis, collaboration, writing and APA. If you fail to post an initial discussion you will not receive these points, you may however post to your peers for partial credit following the guidelines above. Due to the nature of this type of assignment and the need for timely responses for initial posts and posting to peers, the Make-Up Coursework Policy (effective July 2017) does not apply to Discussion Board Participation. Discussion Question/Prompt [Due Wednesday]      Identify the key functional area(s) of nursing informatics relevant to your current position or to a position you recently held, and briefly describe why this area(s) is relevant.     Identify the informatics competencies you selected as essential to your functional area(s) in which you need improvement (refer to the informatics competencies in your readings and support lesson links).     Describe why these competencies are necessary, and outline a plan for developing these competencies.     Explain how developing nursing informatics competencies would increase your effectiveness as a nurse.  Please be sure to validate your opinions and ideas with citations and references in APA format.  Please review post and response expectations. Please review the rubric to ensure that your response meets criteria. 

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After read the following articles 

https://www.aanp.org/practice/business-practice-management/reimbursement/68-articles/325-medicare-reimbursement

https://www.aanp.org/practice/business-practice-management/reimbursement/68-articles/326-medicare-update

Respond 

 Medicare   or Medicaid – which has greater impact in Florida state? 

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