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NURS FPX 6610 Assessment 3 Transitional Care Plan

Student Name Capella University NURS-FPX 6610 Introduction to Care Coordination Prof. Name Date Transitional Care Plan Introduction Transitional care plays a crucial role in ensuring the quality of care and safety of patients, particularly during shifts between different phases of treatment. This assessment focuses on developing a transitional care plan for Mrs. Snyder, a 56-year-old patient with diabetes admitted to Villa Hospital due to an infected toe. The plan aims to address her healthcare needs and identify communication barriers that may affect the overall transitional process (Korytkowski et al., 2022). Key Elements & Information Needed for High-Quality Treatment Effective patient care relies on precise diagnosis, continuous monitoring, and comprehensive medical records management (Watts et al., 2020). Key elements necessary for Mrs. Snyder’s treatment include: Medical Records Collecting Mrs. Snyder’s medical records enables a better understanding of her health status, facilitating accurate diagnosis and treatment of associated conditions (Chen et al., 2018). Medication Reconciliation Accurate medication reconciliation ensures appropriate treatment, minimizes errors, and improves patient outcomes (Fernandes et al., 2020). Emergency and Advance Directive Information Obtaining advance directive information and understanding Mrs. Snyder’s preferences and religious beliefs are vital for providing patient-centered care and preventing complications (Dowling et al., 2020). Patient Feedback Incorporating patient feedback helps healthcare professionals tailor treatment plans to meet individual needs and enhance patient satisfaction (Moghaddam et al., 2019). Plan of Care and Education Customized care plans and patient education are essential for empowering patients like Mrs. Snyder to manage their conditions effectively (Dyer, 2021). Community and Health Care Resources Access to community resources and support services is critical for preventing adverse outcomes and promoting patient well-being (Yue et al., 2019). Insightful Assessment of Patient’s Needs A comprehensive assessment, including medical tests, prescriptions, counseling documents, and social support, is necessary for seamless transitions and optimal care delivery (Humphries et al., 2020). Importance of Key Elements of a Transitional Care Plan Each key element contributes to the effectiveness of transitional care plans by addressing patients’ unique needs and ensuring continuity of care (Blackwood et al., 2019). Potential Effects of Incomplete or Inaccurate Information on Care Incomplete or inaccurate information can lead to treatment delays, medication errors, and compromised patient safety (Zirpe et al., 2020). Importance of Effective Communication Effective communication fosters trust, enhances collaboration, and reduces the risk of adverse events, ultimately improving patient outcomes (Garcia-Jorda et al., 2022). Potential Effects of Ineffective Communications Ineffective communication may result in treatment delays, health disparities, increased costs, and diminished patient satisfaction (Raeisi et al., 2019). Barriers to the Transfer of Accurate Patient Information Challenges such as staffing shortages, incomplete medical histories, and inadequate training in electronic health records can impede the transfer of accurate patient information (Ilardo & Speciale, 2020; Tsai et al., 2020). Strategy to Establish Absolute Understanding of Continued Care Effective strategies include meticulous planning, follow-up sessions, and clear communication to ensure the seamless transfer of information and improve patient outcomes (Glans et al., 2020). Conclusion A well-executed transitional care plan is crucial for optimizing patient care during healthcare transitions. By addressing key elements, overcoming communication barriers, and implementing effective strategies, healthcare providers can ensure Mrs. Snyder receives the best possible care and support her in managing her diabetes effectively. References Moghaddam, M. A.A., Zarei, E., Bagherzadeh, R., Dargahi, H., & Farrokhi, P. (2019). Evaluation of service quality from patients’ viewpoint. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-3998-0 Blackwood, D. H., Walker, D., Mythen, M. G., Taylor, R. M., & Vindrola-Padros, C. (2019). Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: A systematic review. Journal of Clinical Nursing, 28(23-24), 4276–4297. https://doi.org/10.1111/jocn.15049 Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3). https://bvmj.in/journal/borulkar_2022.pdf Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical records secure storage and medical service framework. Journal of Medical Systems, 43(1). https://doi.org/10.1007/s10916-018-1121-4 Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten the quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51. https://doi.org/10.1016/j.mayocpiqo.2018.11.003 Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives—An international literature review of important considerations for nurses. Journal of Nursing Management, 28(6). https://doi.org/10.1111/jonm.13097 Dyer, E. (2021). It’s about people: Caring agents and satisfied patients are key to a successful healthcare call center culture. Management in Healthcare, 6(2), 134–141. https://www.ingentaconnect.com/content/hsp/mih/2021/00000006/00000002/art00004 NURS FPX 6610 Assessment 3 Transitional Care Plan Fernandes, B. D., Almeida, P. H. R. F., Foppa, A. A., Sousa, C. T., Ayres, L. R., & Chemello, C. (2020). Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy, 16(5), 605–613. https://doi.org/10.1016/j.sapharm.2019.08.001 Fiorillo, A., Barlati, S., Bellomo, A., Corrivetti, G., Nicolò, G., Sampogna, G., Stanga, V., Veltro, F., Maina, G., & Vita, A. (2020). The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Annals of General Psychiatry, 19(1). https://doi.org/10.1186/s12991-020-00293-4 Garcia-Jorda, D., Fabreau, G. E., Li, Q. K. W., Polachek, A., Milaney, K., McLane, P., & McBrien, K. A. (2022). Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07590-6 Glans, M., Kragh Ekstam, A., Jakobsson, U., Bondesson, Å., & Midlöv, P. (2020). Risk factors for hospital readmission in older adults within 30 days of discharge – A comparative retrospective study. 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