ch 6

document

a step-by-step approach to the total care of the patient

process of continually evaluating nursing care to identify specific areas that need changes for improvement.

action that requires a physican's order

recording of pertinent data on the clinical record

judgement of the effectivness of the intervention or plan

performing an intervention and assessing the response

does not require a physicans order, but it does require critical thinking and nursing judgement

actions that come from collaborative care planning

nursing actions aimed at accomplishing a goal or expected outcome

the examination of a series of patient records to determine if nursing care for those patients met particular standards and particular outcomes

improvement of the quality of performance

must be done at a set time

can be done at any time