[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › The nursing process and documentation

# 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 students** A professional nurse may delegate tasks to a nursing auxiliary but stays accountable for the…](https://durgical.com/en/nursing/delegation-and-the-care-team-professional-nurses-nursing-auxiliaries-and-student/)
- [**Implementation and evaluation: was the goal met?** After acting, the nurse compares the patient's condition with the goal and decides whether to…](https://durgical.com/en/nursing/implementation-and-evaluation-was-the-goal-met/)
- [**Nursing assessment: subjective and objective data, sources and frameworks** Assessment is the first phase of the process: gathering and checking data about the person to…](https://durgical.com/en/nursing/nursing-assessment-subjective-and-objective-data-sources-and-frameworks/)
- [**Nursing diagnosis in general terms: actual, risk and health-promotion statements** A nursing diagnosis is the nurse's judgment about how a person is responding to their health…](https://durgical.com/en/nursing/nursing-diagnosis-in-general-terms-actual-risk-and-health-promotion-statements/)
- [**Planning care: priorities, measurable goals and interventions** Planning means deciding which problem comes first, what result you want and what the team will…](https://durgical.com/en/nursing/planning-care-priorities-measurable-goals-and-interventions/)
- [**The nursing process: assessment, diagnosis, planning, implementation, evaluation** The nursing process is the orderly method a nurse uses to get to know the patient, decide what…](https://durgical.com/en/nursing/the-nursing-process-assessment-diagnosis-planning-implementation-evaluation/)

## Safe practice

- [**Handoff and SBAR communication** SBAR puts information into four parts so that nothing important is lost when handing over a…](https://durgical.com/en/nursing/handoff-and-sbar-communication/)
- [**Nursing documentation: principles, formats and legal value** If it is not recorded, it is not on record: nursing notes tell, in order and truthfully, the…](https://durgical.com/en/nursing/nursing-documentation-principles-formats-and-legal-value/)
- [**Patient education and teach-back** Teaching the patient is part of care; you check they understood by asking them to explain it, or…](https://durgical.com/en/nursing/patient-education-and-teach-back/)

## A to Z

- [A](https://durgical.com/en/nursing/a-z/a/)
- [B](https://durgical.com/en/nursing/a-z/b/)
- [C](https://durgical.com/en/nursing/a-z/c/)
- [D](https://durgical.com/en/nursing/a-z/d/)
- [E](https://durgical.com/en/nursing/a-z/e/)
- [F](https://durgical.com/en/nursing/a-z/f/)
- [G](https://durgical.com/en/nursing/a-z/g/)
- [H](https://durgical.com/en/nursing/a-z/h/)
- [I](https://durgical.com/en/nursing/a-z/i/)
- [J](https://durgical.com/en/nursing/a-z/j/)
- [K](https://durgical.com/en/nursing/a-z/k/)
- [L](https://durgical.com/en/nursing/a-z/l/)
- [M](https://durgical.com/en/nursing/a-z/m/)
- [N](https://durgical.com/en/nursing/a-z/n/)
- [O](https://durgical.com/en/nursing/a-z/o/)
- [P](https://durgical.com/en/nursing/a-z/p/)
- [Q](https://durgical.com/en/nursing/a-z/q/)
- [R](https://durgical.com/en/nursing/a-z/r/)
- [S](https://durgical.com/en/nursing/a-z/s/)
- [T](https://durgical.com/en/nursing/a-z/t/)
- [U](https://durgical.com/en/nursing/a-z/u/)
- [V](https://durgical.com/en/nursing/a-z/v/)
- [W](https://durgical.com/en/nursing/a-z/w/)
- [Y](https://durgical.com/en/nursing/a-z/y/)

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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.

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Source: https://durgical.com/en/nursing/areas/process/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/areas/process/