NR 575 Week 2 Objective Revision Memo Example

Objective Revision Memo for the Second Rotation: Five Aims Carried From the Intermediate Care Placement, One Standing, Three Superseded and One Struck

Student Name

College of Nursing, Chamberlain University

NR 575: Acute Care Practicum II

Instructor Name

Month Day, Year

Objective Revision Memo for the Second Rotation: Five Aims Carried From the Intermediate Care Placement, One Standing, Three Superseded and One Struck

Summary of the Revision

Five aims came in from the first rotation, on a medical intermediate care unit. One stands as written. Three are superseded by sharper versions written for the second rotation, in a medical intensive care unit at a university hospital. One is struck because the first rotation closed it. No new aim has been added; each surviving aim has a parent in last term's file. The revised set was discussed with my new preceptor, an acute care nurse practitioner on the intensive care team, on the first day of the rotation.

Aim 1: Presenting on Rounds

As it stood last term: four or more hallway presentations with my plan stated before the preceptor's, inside six weeks.

As it stands now: unchanged.

What forced the decision: the aim was met by week 8 last term, with six forms marked. I am keeping it because rounds in the intensive care unit are different: the attending intensivist leads, a respiratory therapist, pharmacist, dietitian and bedside nurse speak on every patient, and each patient's plan is longer. My preceptor agreed that meeting it on an intermediate care unit does not show it here.

State: stands.

Aim 2: Ventilation Decisions

As it stood last term: three bilevel mask decisions, whether to begin or to wean, with a cosigned note for each.

As it stands now: make the daily ventilator decisions for three intubated patients for at least two consecutive days each, covering mode, settings and readiness for a spontaneous breathing trial, documented in cosigned notes.

What forced the difference: last term I met the noninvasive aim, including one start, after asking for two days with the rapid response service. The first rotation also showed me that I had never managed an invasive ventilator, which is daily work in this unit. The new aim moves from a mask to a tube and from a single decision to a sequence of days.

State: superseded.

Aim 3: Admission Notes

As it stood last term: eight problem-based admission notes, each reviewed.

State: struck.

What forced the decision: the aim was met with eleven notes last term, and my preceptor's comments on the last four asked for nothing new. Writing admission notes remains part of the daily work here, but it no longer needs to be an aim. The aim was met, not abandoned, and the closing summary from last term records the count.

Aim 4: Procedures

As it stood last term: a pair of peripheral lines placed under ultrasound, supervised, replaced at the midpoint, under hospital policy, by two arterial punctures with a respiratory therapist observing.

As it stands now: place two radial arterial lines under ultrasound with the intensive care nurse practitioner or intensivist in the room, after observing one, and record each in a procedure note.

What forced the difference: the replacement aim was met last term, and the original was unreachable for policy reasons. This unit allows students to place arterial lines under direct supervision after the hospital's procedure course, which I completed in orientation week. The new aim is one step beyond the arterial puncture: a device that stays in.

State: superseded.

Aim 5: Family Meetings

As it stood last term: run one meeting with a family about goals, preceptor in the room, having first watched one.

As it stands now: lead two family meetings about goals of care with the preceptor present, the first by week 4, and in each, after giving the most difficult information, pause and ask what the family is thinking before raising any option; the preceptor writes one comment on that moment for each meeting.

What forced the difference: I led one meeting last term. My preceptor's written comment, and my own closing summary, both identified the moment after bad news as the weak point. Reviews of serious illness communication describe responding to emotion as a step of its own, before decisions (Bernacki & Block, 2014).

State: superseded.

An Aim Discussed and Not Adopted

My new preceptor suggested an aim about assisting with bedside bronchoscopy, which the unit does often. I considered it and did not adopt it. Nothing in last term's documents points to it, the role of an acute care nurse practitioner in bronchoscopy on this unit is limited to sedation and monitoring, which I already practice with intubated patients, and adding it would spread the term across six aims when four already need the time. We agreed to treat bronchoscopy as an opportunity to watch, not an aim to report, and to revisit the decision at the midpoint if the unit's case mix suggests otherwise, since the preceptor knows the unit far better than I do.

The Preceptor's Changes to My Draft

My draft of aim 2 asked for one patient over five days. My preceptor changed it to three patients over two days each, because the unit's ventilated patients often stay only two or three days, and because three different patients would test the decisions more than one long stay. My draft of aim 5 did not say who would write the comment; my preceptor added that it would be written the same day. Both changes are kept in the wording above. I agreed with the first after seeing the unit's census, and with the second because a comment written days later would describe my memory of the meeting rather than the meeting.

What the Revision Does Not Do

It does not add aims for things this unit happens to offer, such as central lines or bronchoscopy, because nothing in last term's file points to them. Aims grounded in a specific gap are more useful than aims grounded in opportunity, and each aim here can be traced to a sentence in last term's documents. Self-assessment without documents is unreliable (Davis et al., 2006), so each state above rests on a count or a written comment that faculty can find in the first rotation's file.

How the Set Will Be Checked

At the week 5 appraisal each aim will be reported in this memo's wording with a verdict and evidence, and at the closing memo in week 8 again, in this order. Feedback tied to a stated aim is what lets both the student and the preceptor see the same thing (Ende, 1983).

References

Bernacki, R. E., & Block, S. D. (2014). Communication about serious illness care goals: A review and synthesis of best practices. JAMA Internal Medicine, 174(12), 1994-2003. https://doi.org/10.1001/jamainternmed.2014.5271

Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. JAMA, 296(9), 1094-1102. https://doi.org/10.1001/jama.296.9.1094

Ende, J. (1983). Feedback in clinical medical education. JAMA, 250(6), 777-781. https://doi.org/10.1001/jama.1983.03340060055026