1 hours ago Purpose: Guidelines for writing patient case reports, with a focus on medication-related reports, are provided. Summary: The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a … >> Go To The Portal
Patient case reports are valuable resources of new and unusual information that may lead to vital research. Patient case reports are valuable resources of new and unusual information that may lead to vital research. How to write a patient case report
□ List the patient’s present illness. □ List the patient’s medical history. □ List the patient’s family history. □ List the patient’s social history. □ List the patient’s medication history before admission and throughout the case report.
The discussion should evaluate the patient case for accuracy, validity, and uniqueness; compare and contrast the case report with the published literature; and derive new knowledge and applicability to practice.
Patient perspective section 2.13.1. Explanation episode of care. They may describe their moti vations for or the impact of care on their quality of life. The report of perspec tive. Patients can be coa uthors, wh ich may re quire additional consent, owing to the loss of anonymity. A perspective when appr opriate. In some cases, the line is
This is known as safe harbor de-identification.
A case report is an unsystematic clinical observation that states the outcome or response of a single patient to a diagnostic strategy or treatment . Case reports serve to document and share novel cases amongst the medical community for educational purposes.
When safe harbor de-identification is not possible or the opportunity to identify the patient exists, even after de-identification, the expert determination method for de-identification can be considered. For purposes of de-identification, an expert is defined as: A person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable:
When case reports describe or discuss unique or rare circumstances, as they often do, it may be difficult or impossible to de-identify those cases such that there is no reasonable expectation that the individuals included can be identified, so patient authorization generally would be required.
It is important to understand that determining whether data are de-identified under HIPAA is a more restrictive determination than determining whether private information is individually identifiable under the Common Rule. The HIPAA rule considers PHI as any information that may identify an individual; was created or received by a member of a HIPAA covered entity; and relates to the individual's past, present, or future physical/mental health or condition, health care, or payment for health care. HIPAA recognizes two methods for de-identification of data.
Gastric Gavage (Tube)Feeding. Patients who have the inability to ingest, swallow or chew foods but are able to digest and absorb nutrients require feeding via tubes. Tube feedings deliver liquid feeding formula directly to the stomach, duodenum or jejunum. For a patient who cannot normally eat due to dysphagia, ...
The body requires food to provide energy for organ function, replace and repair cells and speed up recovery from illness. Hence, for patients who have trouble swallowing or chewing food, gastric gavage feeding is one important procedure nurses have to implement and master.
Cover the end of the feeding tube with its plug or cap or clamp the proximal end of the feeding tube to prevent leakage and contamination of the tube. Remove and dispose of gloves in a proper receptacle. Document time, amount and type of feeding.
NEVER administer a tube feeding until you are sure the tube is properly positioned in the stomach. Administering feeding through a misplaced tube can cause the formula to enter the lungs. To check tube patency and position, remove the cap or plug from the tube feeding and use a syringe to aspirate stomach contents.
Administering cold formulas can increase the chance of diarrhea. Do not warm the formula in direct heat or microwave as it may cause the solution to curdle and the chemical composition. Also, a hot formula can injure the patient.