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fundamentals unit 3

QuestionAnswer
The nursing process is? A systematic, rational method of planning and providing individualized nursing care for individuals
Assessment in the nursing process is? A systematic process where the nurse through interaction with the patient collects and analyzes data about the patient.
Nursing diagnosis in the nursing process is? A interpretation of the assessment data. It can also be potential or actual health care concerns
Planning in the nursing diagnosis is? Setting goals and priorities
Implementation in the nursing process is? Nursing interventions
Evaluation in the nursing process is? Objective and subjective data which determines the extent to which the goal has been achieved.
Documentation is? A legal document that provides an account of the patients relationship with the healthcare facility.
The purpose of documentation is? History for other shifts Communication plan of care Quality of insurance
A method of training would be traditional which means? An organized by specialty
Problem oriented charting? data arranged by clients problems encourages collaboration
Soap charting Subjective Objective Assessment Plan
Focus charting Limited to one specific event/abnormal assessment data
Charting by exception Frequently kept by the bed side Eliminates repetitive charting
Computer assisted Goals toward safety to access information
EMR electronic medical record
Created by: aarrell05
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