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Provide an experience in which you effectively compiled and recorded medical charts, reports, and/or correspondence?

#healthcare #CMAA #nursing

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Subject: Career question for you

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Suzanne’s Answer

Hello Exzaveha,

I love to tell this story. My background is in oncology (cancer) nursing. I specialized right out of nursing school and achieved multiple certifications in cancer nursing.

I was working in a very large metropolitan private practice with 7 physicians and 20 other staff. The practice owner, Dr. M., had been taking care of a woman diagnosed with a rare lymphoma for over 15 years. He could not remember all of her prior treatments. Now, this was in the days of paper records prior to electronic documentation. Her paper charts, stacked on top of each other, were about 3 feet tall. Dr. M asked me to research her entire record, to abstract out her prior diagnosis dates, biopsy reports, and full treatment summaries. He was attempting to determine if he could offer her any future treatment in light of her disease recurring.

It took me two days of concentrated work, but I was able to provide a 2 page summary of her treatment history. Dr. M then was able to find available clinical trials that suited her needs.

Even with electronic records that are used today, many clinic and hospital databases are not interconnected. It is up to the patient to track their records and then up to very committed healthcare staff to incorporate outside records into the patient's current care setting.

You asked a very important question.

I hope this story was helpful.

Sue
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Cinthya’s Answer

Every shift of my nursing life.
You are documenting everything you do every hour.
Vitals. Doctor rounds. Interventions. Medications given. Phone calls and notifications.
Care plans and changes.
Family conversations and updates.
The documentation of info is endless in medicine.
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