Patient Tracer Summary

By carrying out an assessment nurses can identify the causes of problems that require medical involvement. Nettina (2006)

Explain legal issues, policies and procedures relevant to assessment, including those for confidentiality, health, safety and welfare

This unit must be assessed in accordance with Skills for Care and Development's QCF Assessment Principles.

I was able to gather a lot of information on my patient when I was taking his health history, giving his shift assessment, and reviewing his charts. I used this step to offer effective nursing care to determine the priorities of what is the most important issue for which the patient should be treated.

Willow Bend Hospital’s compliance does indeed have multiple deficiencies and is in need of review as many were updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited.

The ASPIRE framework, also referred to as the nursing process (Barratt, Wilson and Wollands, 2012) was used to structure and develop Susan’s care plan. Introduced by Barrett, Wilson and Wollands (2012), following on from APIE developed by Yura and Walsh (1967), ASPIRE stands for assessment, systematic nursing diagnosis, planning, implementation, recheck and evaluation. Hogston and Marjoram (2006) believe that systematic nursing diagnosis was added to offer direction and time for the nurse to reflect on gathered information and systematically develop a diagnosis. Also the aspect of rechecking is to enable the nurse to monitor and plot a patient’s progress contributing to the final stage of evaluation of care and if its successfulness (Barratt, Wilson and Wollands, 2012).

This booklet is designed to be used as a reminder and reference for people who work in the care profession

The Joint Commission. (2015, June 3). Accreditation Requirements. Retrieved from The Joint Commission E-edition: http://e-dition.jcrinc.com/MainContent

Write a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the “related to” (r/t) factors.

2. Guides, customer records, and work force documents will keep on being requested into courts in light of the fact that the legitimate framework believes the documentation contains data expected to settle on choices about youngster care, automatic hospitalization, and a wide cluster of different circumstances, including assertions of deceptive conduct. Absence of trustworthiness and ineptitude and in addition lost, fragmented, and insufficient graphs can be hurtful to the client and the counselor.

all the solutions for the problems that the nurse would bring up to try and stop

As you learned in NR302, before any nursing plan of care or intervention can be implemented or evaluated, the nurse conducts an assessment, collecting subjective and objective data from an individual. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting both subjective and objective data, synthesizing the data, and identifying health and wellness priorities for the person. The purpose of the assignment is twofold.

Discuss how an understanding of nursing-sensitive indicators could assist the nurses in this case in identifying issues that may interfere with patient care.

* This is to determine if the delivery and assessment meets the requirements of the standards or assessment criteria , the whole assessment process needs to be accutat, consistate, safe and meets all organisation requirements.

Ashton, C., Kuykendall, David H., Johnson, Michael M. (1999). An Empirical Assessment of the Validity of Explicit and Implicit Process-of-Care Criteria for Quality Assessment. 27(8). 798-808.