nursing process documentation n.
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  2. THENURSING PROCESS Includes 5 steps: • Assessment • Diagnosis • Planning and outcome identification • Implementation • Evaluation

  3. THE NURSING PROCESS (continued) • A series of steps that lead to accomplishing some goal or purpose. • A systematic method for providing care to clients. • Provides individualized, holistic, effective and efficient client care. • Clients of all ages and in any care setting.

  4. ASSESSMENT • The first step in the nursing process. • Includes systematic collection, verification, organization, interpretation, and documentation of data.

  5. THE PURPOSE OF ASSESSMENT • To organize a database regarding a client’s physical, psychosocial, and emotional health. • To identify health-promoting behaviors and actual and/or potential health problems.

  6. TYPES OF ASSESSMENT • Comprehensive–provides baseline client data. • Focused–limited to a particular need or health care concern. • Ongoing–includes systematic monitoring of specific problems.

  7. SOURCES OF DATA • Primary source–client or the major provider of information about a client. • Secondary source–sources of data other than client and include family members, other health care providers, and medical records.

  8. TYPES OF DATA • Subjective data–data from client’s point of view, and include perceptions, feelings, and concerns. Collected by interview. • Objective data–observable and measurable, obtained through both physical examination and the results of lab and diagnostic testing.

  9. VALIDATING THE DATA • Prevents misunderstandings, omissions, and incorrect inferences and conclusions.

  10. ORGANIZING THE DATA • Data must be organized. • Data clustering is the process of putting the data together in order to identify areas of the client’s problems and strengths.

  11. INTERPRETING THE DATA • Organizing data in clusters helps to recognize patterns of response or behavior: • Distinguish between relevant, irrelevant. • Determine whether and where there are gaps in the data. • Identify patterns of cause and effect.

  12. DOCUMENTING THE DATA • The nurse must decide which data should be immediately reported and which data can just be recorded. • It is essential for accurate and complete recording of assessment data to communicate information to other health care team members.

  13. DIAGNOSIS • Second step in the nursing process. • Clinical judgment about individual, family, or community response to actual or potential health problems/life processes. • Provides the basis for client care through the remaining steps.

  14. MEDICAL DIAGNOSIS • Clients have both nursing and medical diagnoses. • A medical diagnosis is a clinical judgment by the physician that identifies or determines a specific disease, condition, or pathological state.

  15. TWO-PART NURSING DIAGNOSIS • Part one–problem statement or diagnostic label describing the client’s response to actual or risk health problem or wellness condition. • Part two–etiology or the related cause or contributor to the problem. • Linked by the term related to (r/t).

  16. THREE-PART NURSING DIAGNOSIS • Part one–diagnostic label. • Part two–etiology. • Part three–defining characteristics, or signs and symptoms, subjective and objective data, or clinical manifestations. • Third part linked to the first two by the term as evidenced by (AEB).

  17. TYPES OF NURSING DIAGNOSES • Actual nursing diagnosis–indicates that problem exists. • Risk nursing diagnosis–indicates that specific risk factors are present. • Wellness nursing diagnosis–client’s statement of desire to attain a higher level of wellness in some area of function.

  18. PLANNING AND OUTCOME IDENTIFICATION • Third step of the nursing process. • Includes establishing guidelines for the proposed course of nursing action and developing the client’s plan of care.

  19. PLANNING PHASES • Initial planning–developing a preliminary plan of care. • Ongoing planning–updating the client’s plan of care. • Discharge planning–anticipating and planning for the client’s needs after discharge.

  20. PLANNING INVOLVES … • Prioritizing the nursing diagnoses. • Identifying and writing client-centered long- and short-term goals and outcomes. • Identifying specific nursing interventions. • Recording the entire nursing care plan in the client’s record.

  21. NURSING INTERVENTIONS • Actions performed by nurse to help client achieve results specified by goals and expected outcomes. • Refer directly to the related factors or the risk factors in nursing diagnoses. • Are stated in specific terms. • May change.

  22. CATEGORIES OF NURSING INTERVENTIONS • Independent–initiated by the nurse and do not require an order. • Interdependent–implemented in a collaborative manner by nurse in conjunction with other health care professionals. • Dependent–requires an order.

  23. THE NURSING CARE PLAN • Written guide of strategies to be implemented to help client achieve optimal health. • Begins on the day of admission and continues until discharge.

  24. IMPLEMENTATION • Fourth step in the nursing process. • The performance of the nursing interventions identified during the planning phase.

  25. ORDERS FOR INTERVENTIONS • Specific order–for individual client. • Standing order–standardized intervention written, approved, and signed by a physician, kept on file to be used in predictable situations. • Protocol–series of standing orders or procedures.

  26. EVALUATION • Fifth step in the nursing process. • Determines whether client goals have been met, partially met, or not met. • Ongoing evaluation is essential for the nursing process to be implemented appropriately.

  27. THE NURSING PROCESS AND CRITICAL THINKING • Critical thinkers ask questions, identify assumptions, evaluate evidence, examine alternatives, and seek to understand various points of view. • Critical thinking can be learned.

  28. DOCUMENTATION • Any printed or written record of activities. • Recording and reporting are the major ways health care providers communicate. • The client’s medical record is a legal document of all activities regarding client care.

  29. PURPOSES OF DOCUMENTATION • Communication • Practice and legal standards • Reimbursement • Education • Research • Nursing audit

  30. COMMUNICATION • Documentation confirms the care provided to the client and clearly outlines all important information regarding the client.

  31. PRACTICE AND LEGAL STANDARDS The legal aspects of documentation require: • Writing legible and neat • Spelling and grammar properly used • Authorized abbreviations used • Time-sequenced factual and descriptive entries

  32. PRACTICE STANDARDS INCLUDE: • State Nursing Practice Acts • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) • Confidentiality • Informed consent • Advance Directives

  33. REIMBURSEMENT • The federal government requires monitoring and evaluation of quality, appropriateness of care provided. • Documentation of intensity of services and severity of illness reviewed. • Failure to document can result in reimbursement denied.

  34. EDUCATION • Health care students use medical record as tool to learn about disease processes, nursing diagnoses, complications and interventions. • Students can enhance critical-thinking skills by examining the records and following health care team’s plan of care.

  35. RESEARCH • The client’s medical record is used by researchers to determine whether a client meets the research criteria for a study. • Documentation can also indicate a need for research.

  36. NURSING AUDIT • Method of evaluating the quality of care • Includes: • Safety measures • Treatment interventions and responses • Expected outcomes • Client teaching • Discharge planning • Adequate staffing

  37. PRINCIPLES OF EFFECTIVE DOCUMENTATION • Document accurately, completely, and objectively, including any errors. • Note date and time. • Use appropriate forms. • Identify the client. • Write in ink. • Use standard abbreviations.

  38. PRINCIPLES OF EFFECTIVE DOCUMENTATION (continued) • Spell correctly. • Write legibly. • Correct errors properly. • Write on every line. • Chart omissions. • Sign each entry.

  39. Narrative charting Source-oriented charting Problem-oriented charting PIE charting Focus charting Charting by exception Computerized documentation Critical pathways SYSTEMS OF DOCUMENTATION

  40. NARRATIVE CHARTING • Traditional method of nursing documentation. • Chronologic account in paragraphs describing client status, interventions and treatments, and client’s response. • The most flexible system. • Usable in any clinical setting.

  41. SOURCE-ORIENTED CHARTING • Narrative recording by each member of the health care team on separate documents.

  42. PROBLEM-ORIENTED CHARTING • SOAP, SOAPI, AND SOAPIER • S: subjective data • O: objective data • A: assessment data • P: plan • I: implementation • E: evaluation • R: revision

  43. PIE CHARTING • P: problem • I: intervention • E: evaluation

  44. FOCUS CHARTING • System using a column format to chart Data, Action, and Response (DAR).

  45. CHARTING BY EXCEPTION • Only significant findings (exceptions) are documented in a narrative form. • Presumes that unless documented otherwise, all standardized protocols have been met and no further documentation is needed.

  46. COMPUTERIZED DOCUMENTATION • Reduces time taken, increases accuracy. • Increases legibility. • Stores, retrieves information quickly. • Improves communication among health care departments. • Confidentiality and costs can be problems.

  47. CRITICAL PATHWAY • Also known as Care Maps. • Comprehensive pre-printed standard plan reflecting ideal course of treatment for diagnosis or procedure, especially with relatively predictable outcomes. • Additional forms are needed to complement the pathway.

  48. NURSE’S PROGRESS NOTES • Document client’s condition, problems, complaints, interventions, and client’s response to interventions. • Include MAR, vital signs records, flow sheets, and intake and output forms.

  49. DISCHARGE SUMMARY • Client status on admission and discharge • Brief summary of the client’s care • Intervention and education outcomes • Resolved and unresolved problems • Client instructions about medications, diet, food-drug interactions, activity, treatments, follow-up, and other needs

  50. DOCUMENTATION TRENDS • Nursing Minimum Data Set (NMDS) • Nursing Diagnoses • Nursing Interventions Classification (NIC) • Nursing Outcomes Classification (NOC)