The nursing process and documentation
Assessment, diagnosis, planning, implementation and evaluation; records, handoff and patient education.
9 pages
Fundamental
- Delegation and the care team: professional nurses, nursing auxiliaries and studentsA professional nurse may delegate tasks to a nursing auxiliary but stays accountable for the…
- Implementation and evaluation: was the goal met?After acting, the nurse compares the patient's condition with the goal and decides whether to…
- Nursing assessment: subjective and objective data, sources and frameworksAssessment is the first phase of the process: gathering and checking data about the person to…
- Nursing diagnosis in general terms: actual, risk and health-promotion statementsA nursing diagnosis is the nurse's judgment about how a person is responding to their health…
- Planning care: priorities, measurable goals and interventionsPlanning means deciding which problem comes first, what result you want and what the team will…
- The nursing process: assessment, diagnosis, planning, implementation, evaluationThe nursing process is the orderly method a nurse uses to get to know the patient, decide what…
Safe practice
- Handoff and SBAR communicationSBAR puts information into four parts so that nothing important is lost when handing over a…
- Nursing documentation: principles, formats and legal valueIf it is not recorded, it is not on record: nursing notes tell, in order and truthfully, the…
- Patient education and teach-backTeaching the patient is part of care; you check they understood by asking them to explain it, or…
A to Z
← Nursing: fundamentals and procedures
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Representative model, for educational purposes only.