Question

Documentation is anything written or printed on which one relies as record or proof of patient actions and activities. In not less than two pages describe FIVE (5) guidelines for quality nursing documentation at the ward.

Answer 1

the internationally accepted nursing process consists of five steps

1.assessment

2.nursing problem/diagnosis

3.goal

4.intervention

5.evaluation

nursing process model provides the theoretical framework for nursing documentation.a nurse can follow this model to assess the clinical situation of a client and record a constructive document for nursing communication.

assessment

this is the first step and which involves critical thinking skills and data collection; subjective data:-it involves verbal statement from the patient or caregiver.objective data:-this is measurable , tangible data such as vital signs, intake and output and height and weight.

critical thinking skills are essential to assessment thus the need for concept-based curriculum changes.

diagnosis

the formulation of a nursing diagnosis by employing clinical judgement assists in planning and implementation of patient care.

a nursing diagnosis, according to the north American nursing association , which provide up to date list of nursing diagnosis. they defined as a clinical judgment about responses to actual or potential health problems on the part of the patient,family or community.

a nursing diagnosis encompasses maslow's hierarchy of needs and helps to prioritize and plan care based on patient-centerrd outcomes.this includs basic physiological needs,safety and security,love and belonging,self-esteem andself-actualization.

planning

the planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidlines.these patient specific goals and the attainment of such assist I ensuring a positive outcomes.nursing care plans are essential in this phase of goal setting.goal should be specific,measurable or meaningful,attainable or action oriented,realistic or results oriented,timely or time oriented.

implementation

in this step which involves action or doing and the actual carrying out of nursing interventions outlined in the plan of the care.

evaluation

this final step of the nursingprocess is vital to a positive patient outcomes.whenever a health care provider intervents or implements care ,they must reassess or evaluate to ensure the desire outcomes has been met.