You are asked about a diagnosis you are unfamiliar with. Where would you start looking for information? How would you determine how valid the information is?
Expert Answer and Explanation
Collecting and Evaluating Diagnostic Data
The diagnosis of unfamiliar cases can be challenging at times. However, a nurse can follow the (subjective, objective, assessment, and plan (SOAP) model to tackle the responsibility. I will start by identifying the case or the patient to be diagnosed. The patient will be the base of the diagnosis because he or she is the one who will provide much information that will be used to provide a final decision. The patient will help me get subjective data. In the subjective data, I will get the chief complaints and other vital information. The data include medical history, immunization history, the patient’s social history, and allergies. I will also review the patient’s symptoms. After that, I will collect objective data. The objective data will be gathered through tests and laboratory examinations. Evidence-based practices and researches will be so helpful to me when recommending lab tests to be done on the patient. I will combine the objective data and subjective information to and write an assessment. A treatment plan will be created based on the collected information.
The technique that will be used to validate the information in this diagnosis is the internal validation using additional parameters. This method can be used to validate algorithms with diagnostic codes only (Nissen, Quint, Morales & Douglas, 2019). This validation method is often used to check whether or not the patient has received medication or has the symptoms of the condition assessed. This diagnostic method requires that the person applying has a good degree of completeness in data parameters (Recalde et al., 2019). The validation method will help me determine whether I have collected correct information, recommended the right tests, and write the right assessment.
Nissen, F., Quint, J. K., Morales, D. R., & Douglas, I. J. (2019). How to validate a diagnosis recorded in electronic health records. Breathe, 15(1), 64-68. DOI: 10.1183/20734735.0344-2018
Recalde, M., Manzano-Salgado, C. B., Díaz, Y., Puente, D., Garcia-Gil, M. D. M., Marcos-Gragera, R., … & Duarte-Salles, T. (2019). Validation Of Cancer Diagnoses In Electronic Health Records: Results From The Information System For Research In Primary Care (SIDIAP) In Northeast Spain. Clinical Epidemiology, 11, 1015. doi: 10.2147/CLEP.S225568