Assessment
➔Gather Data (subjective and objective) ➔BEST source is the patient
➔Can be comprehensive or problem focused ➔Learn as much as you can about your patients ➔Identify the most RELEVANT information ➔Use your past experience
Diagnosis
➔Identify the problem
➔3 Types (Problem focused, Risk, Health promotion)
Diagnostic statement:
Diagnosis + Related To + As Evidence By (Problem) + (Etiology) + (S/S)
Planning
➔Develop goals (General statement about what we want to happen) and outcomes (Measurable change that must be achieved to meet the goal)
Must be SMART outcomes:
Specific Measurable Attainable Realistic Timely
Implementation
➔The things we will do to help the patient achieve the goals and outcomes
➔Must be relevant and explainable ➔Should include a rationale with citation
Evaluation
➔Were the goals met? Yes or No? Why or Why not?
➔If not explain why and what changes will need to be made