nursing report assignment

A report sheet (also called a "brain sheet") is simply a reference used by nurses so they can keep track of important information about each patient. This sheet is often filled out with key information during change-of-shift report and then updated as things change (and they always do!). The brain sheet is then used at the end of shift to give report to the oncoming nurse. Having a good brain sheet is key for patient safety and effective communication.

✏️ Download the Clinical Success Pack and get report sheets for ICU, Med Surg and Telemetry

Need more info on how use a brain sheet for report?

Here's what a Med-Surg brain sheet looks like at the beginning and end of shift. I'll talk you through each component in the video below (scroll down!).👇

How to use a brain sheet tutorial video

In this quick video, I'm talking you through how to use a report or "brain" sheet at the beginning and end of your shift. Watch to learn the components of a report sheet, how to use each section, and how to utilize this document to give end-of-shift-report.

✏️ Click here to download the FREE Clinical Success Pack, which includes report sheets for ICU, Med Surg and Telemetry.

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37 comments.

Nurse Mo, I think your website is the best! I will be starting my 4th semester nursing thru an ADN program. I’m typically an A and B student, but I missed the mark by 2 points for 3rd semester and received a C. Hopefully 4th won’t totally bog me down! However, I usually do pretty good with clinical, but this semester we will be on our own, so looking forward to all the goodies you have provided. Thank you for unselfishly thinking of us when you have a career and family to think about.

Good luck with 4th semester…you’ll do great! This is when it all comes together…you’ll be surprised how much you know (and also surprised at how much there is still to learn). Stay focused on the patient and TAKE CARE of yourself and all will be well 🙂

Do you have anything related to a brain for a med -surg floor ? I love the flow of yours and all the details, I am just not an ICU nurse.

I’ll have to look Becca…I think I have a link to a tele one…that should work for M/S.

If you are still looking, check out the one I have created for med surg https://nurseologyblog.wordpress.com/2016/02/26/shift-at-a-glance-checklist/

Hope that helps!

Would you happen to have a “brain sheet” that is more geared toward the respiratory system? I’m a Respiratory Therapy/Care student. If not, could you point/lead me in the direction where I may find one?

Good question! I don’t have one and I honestly wouldn’t know how to go about making one! The best thing might be to ask the RTs at the facility where you do your clinical rotations. I know I’ve seen the RTs at my hospital use them, but I never took a close look. Sorry! And best of luck with RT school…such a cool job!

I love your ICU brain sheets? Do you happen to have one I could edit? If not, I understand! Thanks! 🙂

I don’t…the files are huge InDesign files. Thanks for loving them, though!

Hi , do you have any notes biliary and pancreas disorders ? Can you post some please ? Thanks.

Ina…I will look! Maybe I’ll create a case study…been wanting to do that for a long time!

Is their a way to print these? I would love to use these for my handoff 🙂

Hi, is there anyway you can make a labor and delivery one? Im a new l&d nurse and still trying to come up with a more organized way to receive and give report

Hi Celeste! I would have to get help from my L&D friends as I have NO IDEA what sorts of things you need on a brain sheet. If anyone wants to share their insight, I’d be happy to!

Love it. Doesnt quite work for ED. Reiterates the difference between ED and ICU brains to me though. WELL DONE!!

Oh yeah…ED IS TOTALLY DIFFERENT! I’d love to create a brain sheet for the ED, but what I was thinking was make it 4 to a page so you can essentially cut them out into small little “mini brains” to write down just the key info….then toss when that pt leaves. How many patients do you think you see in a day? I imagine it can be a lot!

This is one of the best peripheral brains I have seen. I recently transferred from ED where I was able to keep all that chaos bottled inside my head. The ICU is a completely different animal and I am afraid my poor brain will overload with trying to remember all the labs and vent settings, gtts, etc. Love this brain!

Do you have a link to open these on a word document? I like typing and it would be great to have this there!

Sorry…I don’t use Word 🙁 All my items are created using design programs, but it’s so easy to make your own! I highly encourage people to make their own brain sheets since they will work the way YOUR brain works 🙂

Hey I was wondering if you have a word document copy of this. I would really like to type up my report because my handwriting looks like I am having a seizure during report lol

I would love a copy of the run shift, I work the tele floor and haven’t found one that really suits my needs yet.

Hello! do you have a brain sheet or anything to keep me organized during my shift, I am a new nurse working in the NICU. Thank you!

I don’t have one specific to the NICU, but you could start with the one-patient sheet and then adjust it for your needs. I know there are specific NICU things that don’t apply to adults…let me ask some NICU nurses and see what they suggest 🙂

Nurse Mo, could you please make a “key” for your medsurg brain sheet or show an example of a completed sheet?

Hi Alison…that’s a great idea! In the meantime, please check out my latest podcast episode where I talk you through this sheet step-by-step! https://straightanursingstudent.com/episode108/

Do you have Icu brain for PM shift?

This is the only one I have…I used it for days and NOCs. Are you referring to the run sheet with the time slots on it? It’s possible I have one…send me an email 🙂

Nurse Mo! I’ve been a listener for 2 semesters now and I love your content. It’s detailed and to the point. I get to listen before my lectures so I have an idea of how the content will flow. It’s been helping me through each semester. I’m currently in my last semester doing A LOT of critical care content. My plan is to be somewhere in the Pediatrics, specifically Cardiac. Thanks for being my cheerleader and virtual supporter!

Hi Diana…thanks for the thoughtful feedback! So glad the podcast is helping you!

Hi Nurse Mo! I’m heading into a surgical rotation and would love to use the brain sheet particular to this rotation…when I go to the Etsy link it tells me that this item is no longer available :(. Could you point me in the correct direction for one? Love, love your podcasts!

Hi Monica – the closest one I have currently is the Telemetry Brain – I think you could use that one just fine! And, since many patients on a surgical unit are on telemetry monitoring, you’ll be covered 🙂 Good luck in your surgical rotation!

hello I am a nurse from a non English country, Is the Giving End-of-Shift Report: Episode 7 podcast transcript available?

Not a transcript, but this may help! https://straightanursingstudent.com/be-an-end-of-shift-report-rockstar/

Hi there! I found you through your PACU episode on your podcast! I’m an ICU RN transitioning to PACU. I don’t normally use a template for a brain but with the high pt turnover in the PACU and the frequent reports with anesthesia and OR (and unfamiliar anesthesia/reversal meds), I’m thinking I might need one at the beginning. Do you have a PACU brain or link? Thanks for your episode! Really enjoyed it.

Hi Sophia…welcome to The Good Life 🙂 You’ll LOVE PACU! It’s so great for so many reasons! When I first started I did make a little brain sheet but as I got more experience I realized what I actually needed to write down for my patients and I just do that on the fly.

When we get our patient assignments, they come on a slip of paper that’s about 8.5 inches wide and 4 inches tall. I turn that over and place it vertically…I then create three equal sections.

In the top section I write any PMH that’s relevant to me in the PACU. If they take any meds I need to know about I jot those down here as well. This is also where I include any allergies.

The middle section is for surgery…I write down what meds ANES gave, how long the surgery was (patients often ask, so I like to have it handy), any drains that were added, dressings, blood products, EBL, IVF intake and output (if they had a Foley).

The bottom section is for PACU. On the right side I write my standard to-do list “EKG strip, orders (to remember to get orders if I don’t have them yet), IV Fluids, Care plan, Education, Out note (upon transer). I’ll also add anything specific for that patient like a glucose POC, 12-lead, arm sling, abd binder, x-ray, labs, neuro checks, etc…

And the rest of that bottom section is where I jot down any notes that I’ll need to convey in report.

Easy peasy! I hope that helps!

Nursing Report Writing Guide for Nursing Students

Report writing is essential in any profession, and since nursing is also considered a profession, one must record their work after shift completion. A good nurse report should contain the following details: patient history, diagnoses, vitals labs, medications, and more. Nurses must show accountability for their work and duty to the patient by writing a proper report. An excellent report ensures continuity of care. You are likely to compromise the health and safety of a patient if you don't fill out all the important details. According to studies by John Hopkins University , medical error is the third leading cause of death in the US. For this reason, it's important to know how to write one correctly.

This guide will show you how to write the perfect nursing report.

What is a Nursing Report?

Also known as an end shift report, or a nurse brain, a nursing report is a compilation of all important patient details written by a nurse at the end of a shift. It highlights the record of a patient's medical background, situation, treatment, and care plan. This report helps in facilitating handoffs . For instance, a nurse coming in for their day shift would get a report from the nurse finishing their night shift.

Writing a good nursing report ensures a seamless handover to the incoming nurse who may not be familiar with the patient and their needs.

These reports also go with a patient being transferred to another hospital or department, for instance, if the patient is being transferred from the ICU to the recovery room.

Please keep in mind that nursing reports should be made promptly if they are to serve their purpose.

What to Include in a Nursing Report

A nursing report shows the patient's current medical status. When writing one, there are essential things that you should include. These things are,

Basic information:

• Date of admission
• The patients doctor(s)
• Medical history (all preexisting conditions or any infectious diseases)
• Code status
• Power of attorney
• Advanced directives, for instance, DNR (Do Not Resuscitate)

Current patient health details

• Vital signs (blood pressure, oxygen levels, temperature
• Neuroinflammation
• Musculoskeletal data
• Dietary restrictions
• Wounds or pain points
• The patient took medication
• IV access and the types of fluids

Ongoing patient care information

• Medication dosage and when they should be administered
• Lab results or any pending lab work
• Other tests needed
• How long will the patient stay in the hospital, or when should they be discharged
• Any future procedures that require preparations
• Additional information about requests by the patient

These details are essential; providing them to the incoming nurse helps them keep track of the patient.

Other types of information you will likely see on a nurse report include:

• Patients' preferences, e.g., food, room temperature
• Routine reminders (does the patient require supervised walks)
• Any triggers
• Emergency contact details
• Language barrier (does the patient need a translator)

Steps to Writing a Good Nursing Report

You need to organize the process well to develop an efficient report that won't raise any issues. You must also write it on time to provide the patient with safe and high-quality service.

Follow these steps to fill out your nursing report:

Understand the Purpose of the Report

Before completing the report, you must understand its importance and the application area. This way, you will intelligently communicate the information. Remember that reports not supported by facts are considered useless and worthless.

Use the SOAP Method

The SOAP method is the order in which the medical note is written, and it follows the following plan: Subjective, Objective, Assessment, and Plan. It's vital to arrange your information in the following plan for a professional view.

Nurses use the SOAP method in their reports to make writing easy for others to understand.

Fill in the Basic Information

Begin by filling the template with essential information like the patient's age, sex, date, and time. Include your knowledge as well.

Note that you should not review any routine care procedures now.

Collect Subjective Evidence

Once you have filled in the basic information, collect subjective details from the patient. This information is limited to the knowledge and perspective of the patient or family member accompanying them. Pay attention when you are given this information, especially what they report about their symptoms and past diseases.

Some of the information you will collect about the patient include the pain points and level, the purpose of their visit, and any other concern they might have about their health.

Also, provide any other healthcare problems and diagnoses. Make sure you compare this information to the patient's age.

When collecting this information, you must remain calm and show some level of compassion. You should also be patient, especially when dealing with difficult patients or family members.

Filling in the Objective Information

After collecting all the subjective information from the patient and family members, you should gather objective information. Objective information is that which supports subjective details. Including this information is necessary because it will lead to the patient's diagnosis. Objective information includes the patient's blood work, vitals, observable symptoms, and any tests ordered by the attending doctor.

Also, include any observations you've made about the patients' health and responses. Ensure you stress any recent changes but don't include critical information about the patient's behavior.

Write Down Your Assessment

Assessment involves sorting and analyzing the information provided to learn more and make an informed decision about the patient's health, care plan, and current decision-making.

Jot down the conclusions based on the objective information collected and the conclusion made by the primary care physician. Additionally, include the prescribed medication and how the patient responds to it. Also, note any changes the patient has shown since being administered (are their symptoms improving or worse?)

A lack of assessment can pose a risk to the patient, so you must include this section.

Related: How to write a nursing diagnosis (NDx)

Write a Care Plan

A care plan section outlines the needs and wants of the patients and any interventions you make to meet them. For instance, if the patient needs a lab or imaging test, include it in this section. Also, ask how the patient is responding to the care plan. If, for example, you advise the patient to return to the hospital for a checkup and they fail to show up, include it in the report.

You should write this section well because it will help show the plan's effectiveness. It also acts as evidence that care was given to the patient.

Write Down the Interventions

Interventions are actions you take to help the patient achieve their expected outcomes. This section can include different types of information, including physical treatments, emotional support, and education given to the patients about their ailments, medication, and current or future treatment. Also, include details such as when you gave the patient their medication.

Tips on How to Write a Nursing Report

When filling out a nursing report, you must remember that you are not just writing; you are also communicating. Another nurse or doctor will use your report to decide on the patient's care plan.

As such, nursing reports should be easy to read. Use the following tips to help you write a perfect report.

Ask for Help

If you don't understand how to write the report or which direction to take when asking for information, ask for help. It's not shameful or embarrassing to confess that you don't understand how to fill some sections. Most hospitals and doctors use the SOAP method to write nursing reports, but some offer templates. If you are working in a new hospital or clinic, ask for help from your supervisor. You can also delegate the task to an online nursing/medical report writing service like ours.

Be Objective

Remaining objective as you collect and fill out the nursing report is important.

To be objective is to be unbiased; when you are, it means feelings do not lead you. When collecting data, use your senses: hearing, sight, smell, and touch, to assess the patient. You will collect this type of information during a physical examination.

When you remain objective when collecting this data, you will keep the progress report accurate and precise.

Use Active Voice

Instead of passive voice, use active voice because it is direct. Active voice involves writing sentences with the subject performing the action. Using an active voice in your report will bring clarity by stressing to the reader who is taking action.

Active : I administered 500mg of paracetamol to the patient.

Passive : 500mg of paracetamol was administered to the patient.

The problem with passive voice is that it leaves important details out.

Only Include Important Information

Don't write unnecessary information. You have to find a balance between being detailed and concise. Being concise involves providing as much information with as few words as possible. Rambling around in your report will not serve any purpose but only create confusion. Also, you don't want to include unnecessary information that will make it harder to follow the report. The best way to ensure your report is okay is to use the provided nursing report template.

Use Good Communication

No matter how casual you are with your colleagues or supervisor, it would help if you left this during breaks or outside working hours. You must be professional when writing a nursing report or any other kind of report. You must approach patients to understand their concerns, fears, symptoms, etc. This means that your listening, verbal, and nonverbal verbal skills should always reflect a level of professionalism.

Related Readings:

• How to use the SBAR communication tool
• Making a nursing concept map
• Steps for writing a QI nursing report
• Steps for writing a perfect EBP paper

Add the Information Later

While speaking to the patients and gathering the information, it is important to use an outline and fill in the details later. Finishing consultation ensures you give your all to the patient and what they say. You should also attend to one patient and write the report before proceeding to the next patient because it will help you remember the notes more clearly. However, if you can't finish the notes before attending to the next patient, you should write the most important details first.

Check Other Nurse's Report

Over time, each nurse will develop their voice in the reports. Reading how other nurses, exceptionally experienced ones, have written their reports will help you develop your skill and see improvement areas. Getting inspired by sample nursing or medical reports is a great way to write the best one.

Be Clear on the Priorities

Since a nursing report is given at shift changes, you must be as straightforward as possible. For instance, if you discover a pain relief measure that is effective on the patient during your shift, including the information will ensure the next nurse continues with the same pain relief measure.

Also, if there are procedures that should be conducted as soon as possible, include them in the order they should be done.

Make Your Writing Legible

Please take note that a nursing report aims at ensuring continuity of care. If your text cannot be skimmed, it defeats its purpose. All the information in the report is sensitive, and if you make a mistake, it will have severe consequences for the patient.

When writing the report, write every word, phrase, and sentence well. Also, use the right medical terminology. This way, you will show not only authority but also credibility.

Avoid Late Entries

Late entries are any information absent in the original entry recorded after writing the original report. The problem with late entries is that they tend to introduce inaccuracies. If you must introduce a late entry, ensure you follow the hospital's or clinic's policy on going about it.

Remember that constant late entries will portray you in a bad light.

Write Down All Consulted Physicians

If you consulted any physician while caring for the patient, include it in your report. For instance, if you consulted a gynecologist or oncologist concerning any symptoms the patient was experiencing, mention it in the report. Write them down, starting with their names, titles, times, responses, and resulting actions.

Follow the Facility's Policy on Abbreviations

Even though the use of the medical abbreviation is not a new thing, care should be taken when using them. It's easy to make mistakes by inappropriately using abbreviations. If you have to use abbreviations, ensure they are approved by the facility you work for.

Avoid Hearsay and Personal Opinion

Hearsay or personal statements will carry less weight on the paper. Only write details that are supported by facts. If you have to write personal opinions, use quotations to show them.

Also, be honest in your report, especially when you've made a mistake. Honesty won't always protect you against consequences but will preserve your reputation and moral code.

Common Errors in Nursing Report

Now that you know how to write your report, here are some common errors to avoid.

Omitting Meditation

Knowing the kind of medication that a patient is taking or those that they are allergic to is critical to their care. Always specify every medication they take, the dosage amount, and how the patient reacts to them. In the same manner, knowing that a patient is allergic to penicillin or other antibiotics is the difference between treating them with the right medication or causing more health problems.

Leaving Some Sections Blank

Omitting drugs is wrong, but leaving important sections blank is worse. The incoming nurse expects to find a well-written report to help them continue caring for the patient. If you haven't done this, how will they go on? Blank spaces create ambiguity. Did you leave it blank because treatments weren't administered, or you forgot to write the treatment?

Spending Time on Unnecessary Information

There is such a thing as too much unnecessary information in nursing reports. The aim of these reports is to document the crucial facts that can help with patient care. There are things that you shouldn't put in your report because they are irrelevant, or the next nurse can quickly look up and understand.

Writing unnecessary information will take too much of your time, which you could use to write the next patient's report. Such information includes:

• Non-essential comorbidities. There are patients with a lot of them, which would take time to talk or write about them.
• Every drug the patient is on. Again some patients can have a long list of medications that is not necessary to list. So stick to the important ones.
• Specific labs- if needed, the next patient will have all this information with them.

Using your judgment when writing this is essential to avoid wasting time on unnecessary details. When in doubt, you can always consult your supervisor.

Before you click Exit, ….

Report writing is a crucial part of the nursing routine. A nurse's reports help registered nurses stay organized and capture all the important patient details like diagnosis, vital signs, allergies, pain management plans, and more. Providing this information ensures the next nurse does not risk the patient's life by making mistakes such as failing to prescribe the right medication. The above tips should help you write the perfect nurse report if assigned one as a nursing student.

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You can also trust our legit/reliable nursing writing services to get help. We write 100% original, well-researched, cited, and polished nursing reports for nursing students. Do not let poor grades bother you. Use your time in cursing school to have fun and get deserved rest.

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• How to Write a Report for Your Nursing Assignment: A Step-by-Step Guide

A Step-by-Step Guide to Writing a Nursing Assignment Report

It can be difficult and challenging to write a report for your nursing assignment , but with the right strategy and comprehension of the procedure, you can successfully meet this challenge. This in-depth manual will give you detailed instructions and insightful advice on how to create a report that satisfies the demands of your nursing assignment. Each step of the report writing process will be covered in detail, from comprehending the assignment prompt and conducting in-depth research to organizing your report and presenting your findings. You will discover how to create a compelling introduction that establishes the tone for your report, conduct efficient data analysis and interpretation, and make insightful conclusions. You will also learn helpful hints for editing and proofreading your report to ensure accuracy and clarity. With the help of this manual, you will be able to present your nursing expertise in a well-organized report that adheres to the high academic standards required for your assignment. This manual will give you the skills you need to excel in your nursing assignments, regardless of your level of writing experience or your desire to improve it.

Understanding the Assignment Requirements

It is essential to have a complete understanding of the assignment requirements in order to write a successful report for your nursing assignment. You will be guided through the process of analyzing the assignment prompt, picking out key components, and understanding any particular instructions provided by your instructor in this section. You can decide the scope and focus of your report, the format to use, and the anticipated word count by carefully reviewing the requirements. With this knowledge, you'll be able to customize your report to meet the demands of your assignment and make sure that you cover all the essential points. You will understand the topic, the format of the report, the appropriate sections and headings to include, and any special requirements regarding sources or citation styles by carefully reading the assignment guidelines. You can confidently move on to the following steps conducting research, organizing your content, and creating a well-rounded report that successfully meets the academic expectations once you have a firm understanding of the assignment requirements.

Conducting Thorough Research

In order to compose a report that is thorough, you must first collect information that is pertinent to the subject you have chosen. To begin, you should carry out extensive research utilizing reliable sources such as scholarly journals, textbooks, and reputable websites. Make sure to take notes on the most important points, statistics, and any other information that will support the content of your report. Always make sure to keep track of your sources so that you can properly cite them in the future.

Organizing Your Report

A well-written report must first and foremost have appropriate organization. To get started, draught an outline for the document that details the primary topics as well as the subheadings that will accompany them. The components of a standard nursing report are as follows: an introduction, background information, methods, findings, analysis, conclusions, and recommendations. Adjust the details of your outline so that they correspond to the specific instructions for your assignment.

Writing the Introduction

Your report's tone is established in the introduction, and the reader receives an outline of what to anticipate in the rest of the document. You should begin your report with a sentence that not only catches the attention of the reader but also makes it clear what the purpose of the report is. Give some background information on the subject, and discuss why it is significant within the context of the nursing profession. Include a thesis statement at the end of your introduction. This statement should outline the primary arguments or goals of your report.

Developing the Main Body

The next step is to create the main body of your nursing assignment report once you have a firm grasp of the assignment requirements. In order to effectively present your findings and analysis, you will be guided through the process of structuring and organizing your content in this section. You can improve the readability and coherence of your report by subdividing the main body into logical subsections. The first thing to think about is giving background information on the subject you've chosen. This will establish the background and framework for your report and make sure that the reader is aware of the importance of the topic. You will then go into detail about how you went about gathering information or conducting your research. It is crucial to give a thorough explanation of your methodology, including any ethical issues and any setbacks. You will then concentrate on analyzing your results. This entails analyzing and debating the information you have gathered while looking for trends, patterns, and important observations. You offer insightful commentary and exhibit your capacity for information analysis by critically analyzing the results. To ensure the validity of your conclusions, don't forget to back up your analysis with evidence from your research.

Providing Background Information

To get started, give the necessary background information that is connected to your topic. This may include a general overview of the problem, pertinent theories or concepts, or the context in which the issue occurs. To ensure that the reader comprehends the material at hand, be sure to employ language that is both clear and succinct.

Presenting the Methods

Describe the methods or approach that you used to gather data or conduct your research in this section. Explain the data collection process, the sample size, and any ethical considerations that may have been taken into account, if applicable. Because of this, the reader will have the ability to comprehend the dependability and validity of your findings.

Analyzing the Findings

Make your findings as understandable and well-organized as possible. If you want to effectively illustrate your data, you should use tables, charts, or graphs. The findings need to be interpreted, and analysis should be provided, focusing on any significant patterns, trends, or observations. Always keep in mind that you need to back up your analysis with evidence from your research.

Summarizing and Concluding

Summarising and drawing conclusions from your findings is the last step in writing a report for your nursing assignment. You will summarise the main ideas covered in the report's body in this section and provide a concise summary of the data provided. Summarising enables the reader to quickly understand the key points and findings of your study. Highlight the most important conclusions or suggestions you have made throughout the report while restating your thesis statement. This will help the reader understand the main point and reinforce it. Discussing the implications of your findings for the nursing field is also crucial. Consider how your research fills in any gaps in knowledge, adds to it, or suggests new research areas. This reveals a deeper comprehension of the material and highlights your capacity for critical thought. Last but not least, refrain from adding new information in the conclusion. Instead, offer a thoughtful, impactful conclusion that leaves the reader with a lasting impression. Your nursing assignment report's conclusion and summary work together to form a compelling story that highlights the importance of your work.

Summary of Key Points

It would be helpful if you could provide a brief summary of the most important ideas and findings presented in your report. In this section, we will focus on the most crucial aspects, such as the most significant research findings, the most important recommendations, or the most notable insights gained through analysis. The readers will be able to use this summary as a quick reference, and it will reinforce the main points that were made in your report.

Drawing Conclusions

Draw logical conclusions that address the goals of your report based on the evidence and analysis that you have presented. Consider what the implications of your findings could be for nursing practice or for future research in this field. Discuss the ways in which your report adds to the existing body of knowledge or fills in any understanding gaps it may have uncovered. You can strengthen the relevance and significance of your work by drawing conclusions that are well supported by the evidence.

Editing and Proofreading

Refining written content to ensure that it is clear, accurate, and of high quality requires editing and proofreading to play a significant role. In the editing process, the focus is on improving the flow, organization, and structure of the text, as well as the coherence, sentence structure, and word choice. On the other hand, proofreaders examine the final draught in great detail in order to search for typographical errors, misspellings, grammatical mistakes, and formatting inconsistencies. These processes, when combined, make certain that research papers, business reports, novels, or articles published on websites are presented in a manner that is polished and professional. Writers can effectively communicate their message and engage their target audience by implementing these practices and putting them into practice.

Editing for Clarity and Coherence

Check your report thoroughly to make sure your ideas are organized and flow naturally in this step. Search for any statements that aren't clear or ambiguous, then edit them to make them more precise. Make sure your sentences and paragraphs are well-organized, and that the transitions between ideas are smooth. This editing procedure improves the readability of your report and aids in effectively communicating your message to the reader. Examine the relationships between the various sections of your report in order to maintain a cohesive narrative, and then take into account the overall coherence of your report.

Citations and Referencing

Check to see that all of the sources you used for your report have been properly cited and that your referencing adheres to the required citation style, such as APA, MLA, or Chicago. To ensure accuracy and consistency, compare your in-text citations with the reference list or bibliography. Ensure that all quotations, paraphrases, and ideas taken from other sources are properly cited. The best way to maintain academic integrity and prevent plagiarism is to properly cite your sources.

In conclusion, becoming an expert report writer for your nursing assignment is a skill that will be useful to you both academically and professionally. You can approach your assignments with confidence and create well-structured, informative reports by following the step-by-step instructions provided in this article. Never forget to conduct in-depth research, fully comprehend the assignment requirements, and effectively organize your report. Spend some time crafting a captivating introduction, a logical main body, and a succinct summary and conclusion. For the purpose of polishing and ensuring that your report is error-free, editing, and proofreading are crucial. You can improve your report-writing abilities while also developing your communication and critical thinking abilities in the field of nursing by consistently exercising them. Never undervalue the ability of a well-written report to communicate your knowledge and expertise. Embrace the process, ask for feedback, and never give up.

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Nursing Assessment Forms

39 printable nursing assessment forms (+examples).

People who go to the hospital seeking medical information or help will be first attended by any member of the nursing staff before going to a doctor. As a nurse, you would perform a nursing assessment, which includes height and weight measurements, temperature, blood pressure , heart, and respiratory rate. You record your results in a nursing assessment form.

Table of Contents

• 1 Nursing Assessment Forms
• 2 What is a nursing assessment?
• 3 Nursing Assessment Templates
• 4 Why is a nursing assessment important?
• 5 Nursing Assessment Examples
• 6 How do you write a nursing assessment?
• 7 Nursing Assessment Sheets

What is a nursing assessment?

A nursing assessment form contains a collection of information about the physiological, psychological, spiritual, and sociological status of a patient. The assessment is the first step in the nursing process.

Although you can use nursing skin assessment forms and other forms to identify the current and future needs of a patient, it still has a very broad scope. You should go through certain set procedures before you can properly evaluate an individual.

Typically, you will use a nursing assessment sheet that you will fill up when conducting these evaluations. The nursing assessment is an organized set of processes you use to provide optimal care for your patients.

You cannot delegate this assessment to unlicensed nurses, although nursing students unless with the guidance of their clinical instructors. This assessment has a broad scope because it focuses on the whole body system. There are different types that focus only on specific parts of the assessment. These include:

• Learning Needs Here, you identify deficiencies in knowledge that serve as the basis of the learning needs of a person that you can analyze. This functions as a guide in teaching by a healthcare provider.
• Competency This is the continuous evaluation of the knowledge, skills, and development of a person that enables them to perform activities.
• Physical This is a thorough head-to-toe assessment of a patient.
• Admission Before a patient gets confined in a hospital, they must go through physical assessments and statistics. This serves as a baseline for the required actions you must take and for the patient records.
• Holistic This approach toward a patient involves sociological, cultural, spiritual, and psychological needs. You derive your nursing implementations from the information you gather from your patient.

Nursing Assessment Templates

Why is a nursing assessment important?

In general, nurses know that a comprehensive nursing assessment is an important first step in the development of a plan to deliver the best possible patient care. As a nurse, you also know that a nursing assessment form is a key part of your responsibilities and roles.

A nursing assessment example is a tool used to learn about a patient’s symptoms, overall health, and concerns. A nursing assessment template is an essential factor because this is where you gather comprehensive data to help in the determination of your diagnoses, which you then use to develop nursing care plans to help improve health outcomes.

The comprehensive data on these forms include psychological, socioeconomic, social, and physiological determinants of health, lifestyle, and spiritual information. The comprehensive health assessment has many components.

Before the assessment begins, you must develop a rapport with your patients by first introducing yourself, then explaining what you will do during the assessment and why.

Patients become anxious when you conduct these assessments and establishing a rapport with them helps put them at ease although this could also depend upon the setting of the assessment or the reason for their visit.

Most comprehensive nursing assessments usually begin with the health history of the patient and this includes information about their past injuries or illnesses including childhood immunizations and illnesses, surgeries, hospitalizations, allergies, chronic illnesses, and the illnesses that run in their family.

One of the components of a nursing assessment is the health history of the patient. Here, you will ask a patient to describe the symptoms they feel, when their symptoms began, and how they developed before you forward the process to the physical examination.

Physical examinations are very familiar to most people and they usually start with a complete set of vital signs including blood pressure, respiratory rate, temperature, and heart rate.

Because of the increasing rate of chronic conditions and the growing elderly population, it is necessary to learn how to keep up with distinct patient characteristics. This is another important aspect of the BSN and RN program.

Nursing Assessment Examples

How do you write a nursing assessment?

One of the most important roles of filling out nursing assessment examples is to provide accurate, safe, and effective nursing care. This is the first step in the nursing process and it involves exploring the psychological, physical, social, and spiritual aspects of a patient.

In other words, nursing skin assessment forms and other forms are a systematic and holistic guide for you to gain a better understanding of the needs and wants of a patient. A nursing assessment sheet is the underlying foundation of the process on which you base the other parts of the process.

You use the nursing assessment form as the starting point to building a therapeutic patient-nurse relationship and you can establish this during your first encounter. Actually, the assessment is the first encounter between you and a patient. You will both make first impressions and these judgments can have a great effect on how a patient perceives you.

Through this assessment, you can get information essential for providing your patient with effective holistic care. You can use nursing assessment framework tools to get from a patient, accurate information about them.

The initial assessment, which you based on both objective and subjective data, can be your basis in determining the actual issues of a patient, as well as, any potential issues. When making this assessment, include the following:

• Admission Assessment You should complete this with the patient, a caregiver, or a parent upon the patient’s arrival and you must be complete it within 24 hours of their admission. Then you enter any additional information into the progress notes of the patient. It is important to consider the privacy of your patient at all times.
• Patient History As a nurse, you should discuss the following with your patient: The history of the patient’s current injury or illness Other relevant details about their past history Any allergies and similar reactions Any medications the patient is currently taking Immunization status Implants, social, and family history You should also discuss any recent overseas travel and documented this information Assessment of your patients’ overall emotional, behavioral, and physical state. You should conduct this upon their admission then continue to observe them throughout their stay in the hospital.
• Vital Signs This involves recording baseline observations on your patient’s observation flowsheet. This is an important aspect of admission documentation and assessment. You should complete an ongoing assessment of vital signs as indicated for your patient. It is very important to review the VICTOR graph every two hours or as your patient’s condition requires. This allows you to observe any trending of vital signs that might support your clinical assessment process.
• Physical Assessment Conducting a structured physical examination can help you get a complete assessment of your patient. Some techniques used to obtain this information include inspection or observation, percussion, auscultation, and palpation. You should use your clinical judgment to decide on the extent of the assessment needed. Assessment information includes, but isn’t limited to: Primary assessment Shift Assessment Focused Assessment Neurological System A complete neurological nursing assessment includes sensory function, neurological observations, growth and development including gross and fine motor skills. seizures and other concerns. Respiratory System Generally, children are more susceptible to respiratory illnesses and other similar conditions that cause respiratory distress. Therefore, you should conduct an assessment of the severity of their respiratory conditions. Gastrointestinal Ensure that your patient’s stomach isn’t full when conducting this assessment as this might induce vomiting. This assessment can include inspection, light palpation and auscultation of the abdomen to find visible abnormalities, softness or tenderness and bowel sounds. Musculoskeletal You can conduct this assessment while observing a child or in bed or as they move about a room. Keep in mind that during periods of rapid growth, children usually complain of normal muscle aches. You should compare their joints and limbs bilaterally throughout your assessment. Skin You conduct this to identify any cutaneous issues or systematic diseases. Eye You should perform eye inspection on children very carefully and only when the child is completely compliant. Ear, Nose, and Throat (ENT) Conducting this assessment is important as respiratory illnesses are very common in children. It should also involve a comprehensive examination of the throat, the mouth, and the oral cavity. Common diseases here might include allergies, upper respiratory infections, facial or oral trauma, pharyngitis and dental caries.
• Assessment Evaluation Make sure that the information you collect is properly documented, complete, and accurate before going to the evaluation phase of your assessment. You must use problem-solving and critical thinking skills in making clinical decisions and the plan of care for the patient you’re assessing. Should you discover any abnormal findings, it will be your responsibility to take appropriate action. These actions may include communicating your findings to the medical team, the ANUM in charge of your shift, or related allied health team. Patients should undergo continuous assessment for any changes in their condition while under your care. Moreover, these assessments should be regularly documented.

Nursing Assessment Sheets

More Templates

Referral Form Templates

Client Intake Forms

SBAR Templates

Do Not Resuscitate Forms

Living Will Templates

Health History Forms

The Ultimate Guide to Nursing Assignments: 7 Tips and Strategies

Nursing assignments are a critical component of every nursing student’s academic journey. They serve as opportunities to test your knowledge, apply theoretical concepts to real-world scenarios, and develop essential skills necessary for your future nursing career. However, tackling nursing assignments can often be overwhelming, particularly when you’re juggling multiple responsibilities. In this comprehensive guide, we provide valuable tips, strategies, and expert assignment help services to help you excel in your nursing assignments. Whether you’re struggling with research, structuring your assignment, or proofreading, we’re here to support you every step of the way.

Understanding the Nursing Assignments

To excel in nursing assignments , it’s crucial to start by thoroughly understanding the requirements. Take the time to carefully read the assignment prompt, paying close attention to the topic, word count, formatting guidelines, and any specific instructions provided by your instructor. Understanding these key components will ensure that you meet all the necessary criteria.

Conducting Thorough Research

Once you have a clear understanding of the assignment, it’s time to conduct thorough research. Solid research forms the foundation of any successful nursing assignment. Begin by gathering relevant and credible sources, such as nursing textbooks, scholarly articles, reputable websites , and academic databases specific to nursing. These resources will provide you with evidence-based information to support your arguments and demonstrate your understanding of the topic.

Creating a Well-Structured Outline

A well-structured outline is essential for organizing your thoughts and ensuring a logical flow in your nursing assignment. An effective outline acts as a roadmap, guiding you through the writing process and ensuring that you cover all the necessary points.

At [Your Service Name], our expert writers can assist you in creating a comprehensive outline tailored to your specific assignment. By collaborating with us, you can receive personalized guidance in organizing your ideas effectively and structuring your assignment in a logical manner. Our writers understand the nuances of nursing assignments and can help you identify the most important concepts and supporting evidence to include.

Using a Professional Tone

Maintaining a professional tone throughout your nursing assignment is crucial. As aspiring healthcare professionals, it’s essential to communicate your ideas with clarity, conciseness, and professionalism. Use clear and concise language, avoiding jargon or slang that may hinder the reader’s understanding. Present your arguments and supporting evidence in a logical and coherent manner, demonstrating your ability to think critically and apply nursing principles.

Our expert writers have extensive experience in academic writing within the field of nursing. They possess a deep understanding of the professional tone required for nursing assignments and can ensure that your assignment is written to the highest standards. By collaborating with us, you can receive guidance in maintaining a professional tone and effectively conveying your ideas.

Incorporating Practical Examples

In addition to a professional tone, incorporating practical examples into your nursing assignment can greatly enhance its quality. Practical examples bring theoretical concepts to life, illustrating their application in real-life scenarios. They demonstrate your understanding of nursing principles and showcase your ability to bridge the gap between theory and practice.

Our team consists of experienced nursing professionals who can assist you in incorporating relevant practical examples into your assignment. Drawing from their extensive knowledge and expertise, they can provide you with real-life scenarios or case studies that strengthen the impact and credibility of your work. By collaborating with us, you can elevate the quality of your assignment by demonstrating your ability to apply nursing concepts in practical settings.

Proofreading and Editing

Proofreading and editing are essential steps in the assignment writing process. They ensure that your nursing assignment is polished, error-free, and effectively communicates your ideas. After completing the initial draft, it’s crucial to take a break and return to your work with fresh eyes. During the proofreading stage, carefully review your assignment for grammar, spelling, punctuation, and sentence structure. Correct any errors and inconsistencies that may affect the clarity and professionalism of your writing.

At nursingresearchhelp.com , we have a dedicated team of proofreaders and editors who specialize in nursing assignments. They meticulously review your work, ensuring that it adheres to formatting guidelines and meets the highest standards of academic writing. Our proofreaders and editors will help you refine your assignment, ensuring that it is polished and error-free. By collaborating with us, you can rest assured that your assignment will be thoroughly reviewed and refined before submission.

Seeking Help When Needed

In addition to proofreading and editing, it’s important to seek help when needed. Nursing assignments can be challenging, and it’s perfectly normal to require assistance. Whether you’re facing difficulties in understanding the assignment prompt, need guidance in specific areas, or simply want a fresh perspective on your work, don’t hesitate to reach out for support.

Our friendly and knowledgeable support team is always available to address any questions or concerns you may have. We understand the unique challenges faced by nursing students and can provide you with the guidance and clarification you need. By seeking help when needed, you can overcome obstacles and ensure the successful completion of your nursing assignments.

Mastering nursing assignments is within your reach with the right tips, strategies, and expert assignment help services. At nursingresearchhelp.com we are committed to supporting nursing students in excelling in their academic pursuits. Our experienced writers, proofreaders, and editors can provide personalized assistance throughout the assignment writing process, ensuring that your assignments meet the highest standards of quality and professionalism.

With our help, you can confidently tackle your nursing assignments and overcome any challenges you may face. Visit our website nursingresearchhelp.com to learn more about our services and how we can support you in achieving academic excellence. Whether you need guidance in understanding the assignment, conducting thorough research, creating a well-structured outline, using a professional tone, incorporating practical examples, or ensuring a polished final product, we are here to assist you. Trust us for reliable and professional assignment help tailored to your needs.

Don’t let the challenges of nursing assignments hold you back—reach out to us for reliable and professional assignment help tailored to your needs.

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Common Assignments: Writing in Nursing

Although there may be some differences in writing expectations between disciplines, all writers of scholarly work are required to follow basic writing standards such as writing clear, concise, and grammatically correct sentences; using proper punctuation; demonstrating critical thought; and, in all Walden programs, using APA style. When writing in nursing, however, students must also be familiar with the goals of the discipline and discipline-specific writing expectations.

Nurses are primarily concerned about providing quality care to patients and their families, and this demands both technical knowledge and the appropriate expression of ideas (“Writing in nursing,” n.d). As a result, nursing students are expected to learn how to present information succinctly, and even though they may often use technical medical terminology (“Writing in nursing,” n.d.), their work should be accessible to anyone who may read it. Among many goals, writers within this discipline are required to:

• Document knowledge/research
• Demonstrate critical thinking
• Express creative ideas
• Explore nursing literature
• Demonstrate understanding of learning activities. (Wagner, n.d., para. 2)

Given this broad set of objectives, nursing students would benefit from learning how to write diverse literature, including scholarly reports, reviews, articles, and so on. They should aim to write work that can be used in both the research and clinical aspects of the discipline. Walden instructors often ask nursing students to write position and reflective papers, critique articles, gather and analyze data, respond to case studies, and work collaboratively on a project. Although there may be differences between the writing expectations within the classroom and those in the workplace, the standards noted below, though more common in scholarly writing, require skills that are transferrable to the work setting.

Because one cannot say everything there is to say about a particular subject, writers present their work from a particular perspective. For instance, one might choose to examine the shortage of nurses from a public policy perspective. One’s particular contribution, position, argument, or viewpoint is commonly referred to as the thesis and, according to Gerring et al. (2004), a good thesis is one that is “new, true, and significant” (p. 2). To strengthen a thesis, one might consider presenting an argument that goes against what is currently accepted within the field while carefully addressing counterarguments and adequately explaining why the issue under consideration matters (Gerring et al., 2004). The thesis is particularly important because readers want to know whether the writer has something new or worthwhile to say about the topic. Thus, as you review the literature, before writing, it is important to find gaps and creative linkages between viewpoints with the goal of contributing innovative ideas to an ongoing discussion. For a contribution to be worthwhile you must read the literature carefully and without bias; doing this will enable you to identify some of the subtle differences in the viewpoints presented by different authors and help you to better identify the gaps in the literature. Because the thesis is essentially the heart of your discussion, it is important that it is argued objectively and persuasively.

With the goal of providing high quality care, the healthcare industry places a premium on rigorous research as the foundation for evidence-based practices. Thus, students are expected to keep up with the most current research in their field and support the assertions they make in their work with evidence from the literature. Nursing students also must learn how to evaluate evidence in nursing literature and identify the studies that answer specific clinical questions (Oermann & Hays, 2011). Writers are also expected to critically analyze and evaluate studies and assess whether findings can be used in clinical practice (Beyea & Slattery, 2006). (Some useful and credible sources include journal articles, other peer-reviewed sources, and authoritative sources that might be found on the web. If you need help finding credible sources contact a librarian.)

Like other APA style papers, research papers in nursing should follow the following format: title, abstract, introduction, literature review, method, results, discussion, references, and appendices (see APA 7, Sections 2.16-2.25). Note that the presentation follows a certain logic: In the introduction one presents the issue under consideration; in the literature review, one presents what is already known about the topic (thus providing a context for the discussion), identifies gaps, and presents one’s approach; in the methods section, one would then identify the method used to gather data; and in the results and discussion sections, one then presents and explains the results in an objective manner, noting the limitations of the study (Dartmouth Writing Program, 2005). Note that not all papers need to be written in this manner; for guidance on the formatting of a basic course paper, see the appropriate template on our website.

In their research, nursing researchers use quantitative, qualitative, or mixed methods. In quantitative studies, researchers rely primarily on quantifiable data; in qualitative studies, they use data from interviews or other types of narrative analyses; and in mixed methods studies, they use both qualitative and quantitative approaches. A researcher should be able to pose a researchable question and identify an appropriate research method. Whatever method the researcher chooses, the research must be carried out in an objective and scientific manner, free from bias. Keep in mind that your method will have an impact on the credibility of your work, so it is important that your methods are rigorous. Walden offers a series of research methods courses to help students become familiar with the various research methods.

Instructors expect students to master the content of the discipline and use discipline- appropriate language in their writing. In practice, nurses may be required to become familiar with standardized nursing language as it has been found to lead to the following:

• better communication among nurses and other health care providers,
• increased visibility of nursing interventions,
• improved patient care,
• enhanced data collection to evaluate nursing care outcomes,
• greater adherence to standards of care, and
• facilitated assessment of nursing competency. (Rutherford, 2008)

Like successful writers in other disciplines and in preparation for diverse roles within their fields, in their writing nursing students should demonstrate that they (a) have cultivated the thinking skills that are useful in their discipline, (b) are able to communicate professionally, and (c) can incorporate the language of the field in their work appropriately (Colorado State University, 2011).

If you have content-specific questions, be sure to ask your instructor. The Writing Center is available to help you present your ideas as effectively as possible.

Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation . http://www.hcmarketplace.com/supplemental/3737_browse.pdf

Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm

Dartmouth Writing Program. (2005). Writing in the social sciences . http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml

Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing , 13 (1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html

Wagner, D. (n.d.). Why writing matters in nursing . https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/

Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html

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Documentation and Reporting in Nursing

Documentation systems in nursing serve as essential tools for recording patient information accurately and comprehensively. These systems vary from traditional handwritten charts to sophisticated electronic health record (EHR) platforms. How do these systems ensure patient privacy and confidentiality in an era of increasing digitalization? What are the key challenges faced by nurses in adapting to and utilizing electronic documentation systems effectively? How do documentation standards and regulations influence nursing practice and patient care outcomes?

Table of Contents

Purposes of documenting and reporting, advantages of source-oriented medical record (somr), disadvantages of source-oriented medical record (somr), soap format, soapie format, soapier format, advantages of problem–oriented medical record (pomr), disadvantages of problem–oriented medical record (pomr), components of the pie system:, advantages of the pie system, disadvantages of the pie system, components of focus charting, advantages of focus charting, disadvantages of focus charting, components of charting by exception, advantages of charting by exception, disadvantages of charting by exception, implementation considerations, advantages of computerized documentation, disadvantages of computerized documentation, advantages and disadvantages of case management, advantages of case management, disadvantages of case management, traditional care plan, standardized care plan, features of the kardex system, components of a kardex, benefits of the kardex system, components of nursing discharge & referral summaries, importance of nursing discharge & referral summaries, objectives of good documentation and reporting guidelines, principles of good documentation and reporting, 1. objectivity is the key., 2. mind the time., 3. legible is credible., 4. never too late to be accurate., 5. allergies are priorities., 6. heads up for your abbreviations., 7. no to erasures., 8. think of your ink., 9. be a follower, not a false leader., 10. if it’s not yours, do not share., documenting and reporting.

Quality client care relies heavily on efficient communication among healthcare professionals. Typically, health personnel engage in communication via discussions, reports, and records to ensure seamless coordination and collaboration. A discussion entails an informal verbal exchange among two or more healthcare personnel aimed at identifying or resolving a problem by establishing strategies. A report comprises oral, written, or computer-mediated communication designed to convey information to others. For example, nurses routinely provide updates on clients after a hospital shift.

A record , also referred to as a chart or client record , serves as a formal, legal document offering evidence of a client’s care, whether in written or computer-based format. Despite variations in documentation systems and forms across healthcare organizations, client records typically contain similar information. The act of recording information in a client record is known as charting , documenting , or recording , reflecting the standardized approach to documentation in healthcare settings.

Documentation is anything written or printed that is relied on as a record of proof for authorized persons. Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse .

Documenting and reporting in nursing serve multifaceted purposes crucial for effective healthcare delivery and accountability.

1. Communication. Through documentation and reporting, nurses facilitate seamless communication among healthcare professionals, ensuring the continuity of care and promoting patient safety .

2. Planning Client Care. Detailed documentation aids in the formulation and execution of individualized care plans, providing a comprehensive overview of patient needs, interventions, and outcomes.

3. Auditing Health Agencies. Accurate documentation enables health agencies to assess compliance with regulatory standards, identify areas for improvement, and ensure the provision of high-quality care.

4. Research. Documented data serves as valuable resources for research endeavors, contributing to evidence-based practice and advancements in nursing knowledge and patient care.

5. Education. Documentation and reporting provide valuable learning materials for nursing students and healthcare professionals, offering real-life case studies and examples to enhance understanding and skill development.

6. Reimbursement. Thorough documentation supports reimbursement processes by accurately reflecting the care provided to patients, ensuring proper billing and reimbursement for healthcare services.

7. Legal Documentation. Documentation serves as legal evidence of the care provided, protecting both patients and healthcare providers in case of litigation or disputes.

8. Health Care Analysis. Aggregated data from documentation and reporting systems allow for the analysis of healthcare trends, outcomes, and performance metrics, facilitating continuous quality improvement initiatives and informed decision-making.

Documentation System Methods

Effective documentation systems are integral to ensuring accurate communication, maintaining legal records, and supporting clinical decision-making .

1. Source–Oriented Medical Record

A source-oriented medical record (SOMR) is a traditional format for maintaining patient information, where each department or healthcare provider documents their observations, interventions, and outcomes in designated sections of the patient’s chart.

1. The Traditional Client Record

This method involves organizing patient information into a structured format where each healthcare provider or department has its section for documentation. This makes it straightforward for each team member to record and find information specific to their discipline.

2. Departmental Notations

Each person or department, such as nursing, physicians, or physical therapy, makes entries in separate sections of the client’s chart. This segregation allows each department to use forms and notation styles that best suit their needs, enhancing clarity and specificity in documentation.

3. Convenience and Traceability

The source-oriented approach is convenient because it enables healthcare providers from various disciplines to quickly locate and use the forms specific to their role. It also simplifies tracing information, as each type of data is consistently located in the same section, making it easier to follow the patient’s care journey over time.

4. Examples of Sectional Organization

For instance, the admissions department uses an admission sheet to record initial patient information, the physician uses an order sheet for prescribing treatments, a history sheet for recording the patient’s medical background, and progress notes to document ongoing patient care and outcomes. Each section is tailored to meet the documentation needs of different healthcare providers.

5. Narrative Charting

This traditional method of documentation involves recording patient information in a chronological narrative format within the source-oriented record. Narrative charting allows for detailed descriptions of patient conditions, care provided, and the patient’s response, offering a comprehensive and continuous account of the patient’s health status and care over time. This method is beneficial for capturing the nuances and context of patient care, although it can be time-consuming and less structured compared to modern electronic systems.

Advantages and Disadvantages of Source–Oriented Medical Record

After exploring various methods for structuring patient data, many healthcare organizations begin to consider the benefits and drawbacks of source-oriented charting. Nursing leaders, aiming to facilitate caregiving processes, recognize that addressing the challenges their teams encounter can lead to effective improvement strategies. Here are the key advantages and disadvantages of using source-oriented patient charting:

The following are detailed advantages of using the Source-Oriented Medical Record System (SOMR):

1. Seeing a Patient’s Progress According to Each Care Specialty. With SOMR, healthcare providers can easily monitor the progress and specific interventions made by each discipline. This segmented approach allows specialists to focus on their areas of expertise without being overwhelmed by unrelated data.

2. Visualizing Notes in the Order They Were Written. This method organizes notes chronologically within each section, making it straightforward to locate the most recent updates and treatment plans. This can be particularly useful in rapidly changing clinical situations where up-to-date information is crucial.

3. Tracking Progress Across the Multidisciplinary Team for Coordinated Discharge. By maintaining clear, separate sections for each discipline, SOMR facilitates the tracking of patient progress across various specialties. This helps in coordinating a comprehensive discharge plan that considers all aspects of patient care, ensuring that all necessary treatments and follow-up actions are aligned.

4. Ease of Use for Individual Disciplines. Each healthcare provider can easily locate their specific section, reducing the time needed to find relevant forms and documentation. This can facilitate the process of recording and accessing information for each department.

5. Detailed Documentation. SOMR allows for detailed narrative charting, which can provide a comprehensive and nuanced account of patient care, capturing the context and specifics of patient interactions.

The following are the disadvantages of Source-Oriented Medical Record (SOMR):

1. Difficulty Finding Up-to-date Information in Complex Cases. When patients have multiple comorbidities and are seen by numerous specialists, it can be challenging to quickly find the most current information. The need to search through multiple sections can delay access to critical data.

2. Fragmented Data Among Treating Providers. SOMR often results in fragmented data, as information is siloed within each specialty’s section. This can make it time-consuming to compile a complete picture of the patient’s care, requiring cross-referencing between sections.

3. Limited Cross-Referencing and Silo-Writing. The isolated nature of documentation in SOMR can lead to limited cross-referencing between disciplines. This may result in duplicated information, where the same details are recorded multiple times, or missed information, where critical data is not communicated effectively across departments.

4. Inconsistency in Documentation Styles. Different departments might use varying styles and terminologies for documentation, which can cause confusion and inconsistencies when trying to integrate patient information from multiple sources.

5. Increased Risk of Errors. The separation of records can increase the risk of errors, such as conflicting information or omissions, as each provider might not have access to the full scope of the patient’s history and treatment plans.

6. Time-Consuming Data Compilation. Compiling a holistic view of the patient’s care requires significant time and effort to piece together information from various sections, potentially leading to delays in decision-making and care delivery.

2. Problem–Oriented Medical Record (POMR)

The Problem-Oriented Medical Record (POMR), established by Dr. Lawrence Weed in the 1960s, represents a significant shift in medical documentation by organizing patient data around specific problems rather than by the source of the information. This method is structured to enhance clarity, continuity, and comprehensiveness in patient care.

Establishment by Lawrence Weed. Dr. Lawrence Weed introduced POMR to address the limitations of traditional medical records. His goal was to create a more systematic and problem-focused approach that could improve clinical decision-making and patient outcomes .

Data Organization by Patient Problems. Unlike traditional source-oriented records, where information is compartmentalized by department (e.g., nursing notes , physician orders), POMR arranges all data based on the specific problems a patient is experiencing. This organization begins with a comprehensive problem list, which is the cornerstone of the POMR system. Each problem listed is then documented in a structured format, typically including:

The Four (4) Basic Components

1 . Database. A complete history and physical examination, along with initial lab results and diagnostic tests, provide a baseline of patient information.

2. Problem List. Derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved.

3. Plan of Care. For each identified problem, initial plans are developed and documented. These plans are divided into three categories: diagnostic (further tests needed), therapeutic (treatment plans), and patient education (information provided to the patient).

4. Progress Notes. Using the SOAP (Subjective, Objective, Assessment, Plan) format, progress notes detail ongoing care and updates for each problem. This format ensures consistency and thoroughness in documenting patient care.

Example: SOAP Format or SOAPIE and SOAPIER

The SOAP, SOAPIE, and SOAPIER formats provide structured and systematic approaches to documenting patient care. By following these formats, healthcare providers can ensure thorough and consistent documentation, facilitating effective communication, continuity of care, and informed decision-making. Each additional component (Intervention, Evaluation, and Revision) enhances the depth and adaptability of the documentation, allowing for a dynamic and responsive approach to patient management.

• S  – Subjective data
• O  – Objective data
• A  – Assessment
• P  – Plan
• I  – Intervention
• E  – Evaluation
• R – Revision

The SOAP format is a structured method used for documenting patient care in the Problem-Oriented Medical Record (POMR) system. It provides a clear and systematic way to record clinical information, ensuring comprehensive and consistent documentation.

S – Subjective Data:

• Description: This section includes information provided by the patient about their symptoms, feelings, and perceptions. It often includes the patient’s chief complaint , history of present illness, and any other relevant details expressed during the clinical encounter.
• Example: “The patient reports experiencing sharp chest pain radiating to the left arm for the past two hours.”

O – Objective Data:

• Description: This section contains observable and measurable facts obtained through physical examination, diagnostic tests, and laboratory results. Objective data are factual and can be verified by the healthcare provider.
• Example: “ Blood pressure is 150/90 mmHg, heart rate is 95 bpm, and an ECG shows ST-segment elevation.”

A – Assessment:

• Description: The assessment section provides the healthcare provider’s interpretation and analysis of the subjective and objective data. It includes a diagnosis or a list of potential diagnoses (differential diagnosis).
• Example: “The patient is experiencing symptoms indicative of acute myocardial infarction ( heart attack ).”
• Description: This section outlines the proposed plan of action to address the patient’s problems. It includes diagnostic tests, treatments, interventions, patient education, and follow-up plans.
• Example: “Administer aspirin and nitroglycerin , perform a cardiac catheterization , and admit the patient to the ICU for monitoring and further treatment.”

The SOAPIE format extends the SOAP method by adding two additional components: Intervention and Evaluation.

I – Intervention:

• Description: This section details the specific actions and treatments carried out to address the patient’s problems. It includes medications administered, procedures performed, and other therapeutic interventions.
• Example: “Administered 325 mg of aspirin and 0.4 mg of nitroglycerin sublingually. Initiated intravenous access and started a heparin drip.”

E – Evaluation:

• Description: The evaluation section documents the patient’s response to the interventions. It assesses the effectiveness of the treatments and any changes in the patient’s condition.
• Example: “The patient’s chest pain decreased from 8/10 to 3/10, and repeat ECG shows reduced ST-segment elevation.”

The SOAPIER format further expands SOAPIE by including a Revision component, ensuring a comprehensive approach to patient care documentation.

R – Revision:

• Description: This section involves revisiting and updating the care plan based on the patient’s response and evaluation results. It may involve modifying treatment plans, adding new interventions, or setting new goals.
• Example: “Revised the care plan to include a cardiology consult and additional diagnostics such as a stress test. Adjusted medication dosages based on the patient’s response.”

Advantages and Disadvantages of Problem–Oriented Medical Record (POMR)

Like any system, POMR has strengths and weaknesses that can impact its effectiveness in different healthcare settings. The advantages and disadvantages of utilizing problem-oriented medical records include the following:

The advantages of the Problem-Oriented Medical Record (POMR) include:

1. Encourages Collaboration. POMR promotes teamwork among healthcare providers by ensuring that all members of the care team are aware of the patient’s problems and the planned interventions. This fosters a more integrated and coordinated approach to patient care.

2. Problem List at the Front. Having a problem list at the front of the chart immediately alerts caregivers to the patient’s current and past issues. This centralized list makes it easier to track the status of each problem, ensuring that no issues are overlooked and that all team members can quickly grasp the patient’s overall condition.

3. Improved Patient Care. By systematically addressing each problem, POMR ensures comprehensive patient assessments and targeted interventions, potentially leading to better health outcomes.

4. Clear and Structured Documentation. The standardized format of POMR, including the use of SOAP (Subjective, Objective, Assessment, Plan) notes, helps maintain consistency in documentation, making it easier to follow the patient’s care journey.

5. Enhanced Communication. The clear organization and detailed documentation facilitate better communication among multidisciplinary teams, reducing misunderstandings and improving the continuity of care.

The disadvantages of the Problem-Oriented Medical Record (POMR) include:

1. Varied Ability to Use the Charting Format. Not all caregivers have the same level of proficiency in using the POMR system. Differences in training and familiarity with the required charting format can lead to inconsistencies and errors in documentation.

2. Constant Vigilance Required. Maintaining an up-to-date problem list requires continuous attention and effort. If the list is not regularly updated, it can quickly become inaccurate, compromising the effectiveness of the POMR system.

3. Inefficiency Due to Repetition. Since assessments and interventions often apply to more than one problem, information may need to be repeated in multiple sections. This can be somewhat inefficient and time-consuming, increasing the administrative burden on healthcare providers.

4. Time-Consuming. The detailed nature of POMR documentation can be time-consuming, which may be challenging in fast-paced clinical environments. This can potentially detract from the time available for direct patient care.

5. Learning Curve. Implementing POMR requires training and adaptation for healthcare providers who are accustomed to traditional documentation methods. This initial learning curve can slow down the adoption process and temporarily impact efficiency.

3. PIE (Problems, Interventions, and Evaluation)

The PIE documentation system is an efficient approach to organizing patient information, focusing on Problems, Interventions, and Evaluation. This method aims to simplify and integrate care documentation into a continuous, real-time process.

The PIE documentation model groups information into three categories:

• Problems (P). Identifies and lists the patient’s health issues or nursing diagnoses .
• Interventions (I). Records the specific actions taken to address the identified problems.
• Evaluation (E). Documents the patient’s response to the interventions and the effectiveness of the care provided.

The following are the key components of the PIE (Problem, Intervention, Evaluation) System:

1. Client Care Assessment Flow Sheet

• The flow sheet is a crucial part of the PIE system, providing a structured and organized way to record patient assessments. It includes specific assessment criteria that are often categorized based on human needs or functional health patterns.
• Example: A flow sheet might include sections for vital signs, pain levels, mobility status, and other key indicators of the patient’s health.

2. Progress Notes

• Progress notes in the PIE system are used to document ongoing patient care in a narrative form. These notes are directly linked to the problems identified, the interventions carried out, and the evaluations of those interventions.
• Example: A progress note might detail a nurse’s observation of a patient’s response to a new medication , including any side effects or improvements in symptoms.

Flow sheets are designed with particular assessment criteria to ensure consistency and comprehensiveness. They might be formatted according to frameworks such as Maslow’s hierarchy of needs or Gordon’s functional health patterns. Examples of specific criteria could include sections for physical health (e.g., cardiovascular, respiratory), psychosocial status, and functional abilities (e.g., activities of daily living ).

The PIE system eliminates traditional care plan and integrates into progress notes. The PIE system does away with separate, traditional care plans. Instead, the ongoing care plan is integrated directly into the progress notes, making the documentation process more dynamic and less fragmented. By incorporating the care plan into the progress notes, the PIE system ensures that the care plan is continuously updated and reflective of the patient’s current status and needs.

Advantages and Disadvantages of the PIE System

The following are the advantages and disadvantages of the PIE System:

The advantages of the PIE System include:

1. Efficient Documentation. By combining the care plan and progress notes, the PIE system simplifies the documentation process, reducing redundancy and saving time.

2. Enhanced Continuity of Care. Continuous updates within the progress notes ensure that all care team members are informed of the latest patient status and interventions, promoting better continuity of care.

3. Focused and Relevant Information. The focus on problems, interventions, and evaluations ensures that the documentation remains relevant and directly related to patient care, improving clarity and utility.

The disadvantages of the PIE System include:

1. Potential for Oversight. With the elimination of a separate care plan, there might be a risk of missing long-term goals or broader care strategies that are not immediately linked to specific problems.

2. Learning Curve. Transitioning to the PIE system requires training and adjustment, particularly for staff used to traditional documentation methods.

3. Detail Management. The integrated nature of the system means that maintaining detailed and comprehensive records requires diligence to ensure that no critical information is overlooked or inadequately documented.

4. Focus Charting

Focus Charting is a documentation method designed to prioritize the patient’s concerns, needs, and strengths in the healthcare record. This system helps ensure that patient-centered care is maintained, providing a clear, organized approach to documenting care activities and patient responses.

See also: Focus Charting (F-DAR): How to do Focus Charting or F-DAR

The following are components of focus charting :

1. Client-Centered Focus

• Focus Charting is intended to keep the patient and their concerns at the forefront of the documentation process. This method highlights the patient’s issues, strengths, and achievements, ensuring that care is tailored to their specific needs and circumstances.
• Instead of documenting solely on clinical tasks or assessments, a nurse might focus on a patient’s progress in managing pain , their concerns about upcoming surgery , or their efforts in physical therapy.

2. Three Columns for Recording

• Date and Time. This column logs when the care was provided, offering a chronological view of the patient’s progress and the timing of interventions.
• Focus. The focus column specifies the main issue, concern, or strength being addressed. This could include a specific condition, symptom, behavior, or patient goal. Examples: “Pain management,” “Nutritional status,” and “Patient anxiety about discharge”
• Progress Notes. The progress notes detail the actions taken and the patient’s responses, organized into three categories known as DAR.

3. DAR Format

• D – Data. This section includes subjective and objective information relevant to the focus. It captures the initial assessment and observations that identify the patient’s current status. Example: “Patient reports pain level of 7/10 in the lower back, grimacing when moving .”
• A – Action. This section documents the interventions performed in response to the data. It includes treatments, procedures, patient education, and any other actions taken by the healthcare provider. Example: “Administered prescribed analgesic and assisted patient with repositioning. Educated patient on proper lifting techniques to avoid strain.”
• R – Response. This section records the patient’s reactions and outcomes following the interventions. It evaluates the effectiveness of the actions taken and notes any changes in the patient’s condition. Example: “Patient’s pain level decreased to 3/10 within 30 minutes post- medication . Patient verbalized understanding of lifting techniques.”

Advantages and Disadvantages of Focus Charting

The following are the advantages and disadvantages of focus charting :

Here are the advantages of Focus Charting:

1. Patient-Centered Care. By focusing on the patient’s concerns and strengths, this method ensures that care is tailored to individual needs, promoting holistic and personalized care.

2. Clarity and Organization. The structured format of Focus Charting provides clear and organized documentation, making it easier for healthcare providers to quickly understand the patient’s status and the care provided.

3. Enhanced Communication. The use of the DAR format helps ensure that critical information is communicated effectively among healthcare team members, facilitating better coordination and continuity of care.

4. Comprehensive Documentation. The inclusion of data, actions, and responses ensures that all aspects of patient care are documented comprehensively, supporting better clinical decision-making and care planning .

Here are the disadvantages of Focus Charting:

1. Training Requirements. Implementing Focus Charting requires training for healthcare providers, particularly those accustomed to other documentation methods. This can initially slow down documentation processes.

2. Time-Consuming. Ensuring thorough and detailed entries in the DAR format can be time-consuming, potentially increasing the administrative burden on healthcare providers.

3. Risk of Incomplete Documentation. If not consistently followed, there is a risk of incomplete documentation, particularly if the focus is not updated to reflect new patient concerns or if the response section is neglected.

5. Charting by Exception

Charting by Exception (CBE) is a documentation system that focuses on recording only abnormal or significant findings, or exceptions to established norms. This method aims to facilitate documentation, reduce redundancy, and highlight critical information, making it easier for healthcare providers to quickly identify and address issues that deviate from expected outcomes.

The following are the key components of Charting by Exception:

1. Flow Sheets

• Flow sheets are used to document routine care and normal findings in a standardized, concise format. These sheets include predefined parameters and checklists for various aspects of patient care, such as vital signs, intake and output , and other routine assessments.
• Example: A flow sheet for vital signs might have columns for recording temperature, blood pressure , heart rate , and respiratory rate at regular intervals, with spaces to note any deviations from the norm.

2. Standards of Nursing Care

• Standards of nursing care provide the baseline or normal criteria for patient assessments and interventions. These standards are based on established best practices and clinical guidelines, serving as reference points for what is considered normal or expected.
• Example: For a postoperative patient, the standards might include expected ranges for vital signs, typical recovery milestones, and standard pain management protocols. Deviations from these standards would be documented as exceptions.

3. Bedside Access to Chart Forms

• Bedside access to chart forms ensures that documentation tools are readily available where care is provided. This facilitates immediate recording of exceptions and ensures that critical information is captured in real-time.
• Example: Electronic health records (EHR) systems with mobile tablets or bedside computers allow nurses to quickly document exceptions during patient rounds, reducing delays and improving accuracy.

Advantages and Disadvantages of Charting by Exception

While CBE offers several advantages, such as increased efficiency and clarity in medical records, it also comes with potential disadvantages, including the risk of missing important details and the need for thorough initial assessments and training. What are the specific benefits and challenges of implementing CBE in clinical practice ? The following are the advantages and disadvantages of charting by exception:

The following are the notable advantages of Charting by Exception (CBE):

1. Efficiency. By focusing only on abnormal or significant findings, CBE reduces the time spent on documentation, allowing healthcare providers to allocate more time to direct patient care.

2. Clarity. CBE highlights deviations from the norm, making it easier for care teams to identify and address issues that require attention. This can improve the detection of patient problems and prompt timely interventions.

3. Reduced Redundancy. CBE minimizes repetitive documentation of routine care, reducing the risk of documentation fatigue and errors. This approach ensures that records are concise and focused on relevant information.

4. Enhanced Focus on Patient Needs. By concentrating on exceptions, CBE helps healthcare providers prioritize significant changes in the patient’s condition, facilitating more targeted and effective care.

The following are the disadvantages of Charting by Exception (CBE):

1. Risk of Missing Details. If not properly implemented, there is a risk that important but seemingly routine information might be overlooked or not documented, potentially missing subtle signs of patient deterioration.

2. Dependence on Accurate Baselines. Effective CBE relies on well-defined standards of care and accurate initial assessments. Inaccurate baselines can lead to misinterpretation of what constitutes an exception, compromising patient safety.

3. Training Requirements. Staff must be adequately trained to recognize and document exceptions accurately. Inadequate training can result in inconsistent documentation practices and reduced effectiveness of the CBE system.

4. Potential for Complacency. There is a risk that staff might become complacent, assuming that no documentation implies no issues, which could lead to underreporting of important patient information.

The following comprehensive list outlines the various implementation considerations to be mindful of when adopting Charting by Exception (CBE) as a documentation method within a healthcare setting:

1. Develop Comprehensive Standards of Care. Clearly defined standards are essential for effective CBE. These should be based on evidence-based practices and regularly updated to reflect current guidelines.

2. Ensure Thorough Initial Assessments. Accurate and detailed initial patient assessments establish the baseline for what is considered normal, making it easier to identify exceptions.

3. Provide Adequate Training. Training programs should focus on helping staff recognize significant findings and understand the importance of documenting exceptions accurately.

4. Utilize Technology. Implementing electronic health records (EHR) with decision support tools can aid in identifying exceptions and facilitate the documentation process.

6. Computerized Documentation

Computerized documentation systems have been developed to manage the vast amount of information required in modern healthcare. These systems leverage technology to facilitate the documentation process, enhance accuracy, and improve access to patient information. Here’s a closer look at how computerized documentation functions and its benefits:

1. Managing Large Volumes of Information

• Contemporary healthcare generates extensive amounts of data, including patient histories, diagnostic results, treatment plans, and progress notes. Computerized documentation systems are designed to handle this information efficiently, allowing for secure storage, quick retrieval, and comprehensive management.
• Example: A patient’s entire medical history , from initial consultation to discharge summaries, can be stored in an electronic health record (EHR) system, accessible with a few clicks.

2. Functions for Nurses

• Storing Client Databases . Nurses can input and store detailed patient information in a centralized database, including demographics, medical history, allergies, medications, and more. Example: Upon admission, a nurse enters a patient’s personal information, medical history, and initial assessment into the system.
• Adding New Data. As patient care progresses, new information can be continuously added. This includes updates from ongoing assessments, lab results, and observations. Example: During each shift, nurses update the patient’s vital signs, symptoms, and any changes in condition.
• Creating and Revising Care Plans. Nurses can develop, modify, and update care plans based on real-time patient data. These care plans can be customized to meet individual patient needs. Example: A care plan for a diabetic patient might include regular blood sugar monitoring, dietary adjustments, and medication administration , all updated as the patient’s condition evolves.
• Documenting Client Progress. All aspects of patient care and progress are documented in the system. This includes interventions performed, patient responses, and outcomes. Example: If a patient receives a new medication, the nurse documents the administration and monitors the patient’s reaction, noting any side effects or improvements.

3. Elimination of Multiple Flow Sheets

• In traditional documentation, multiple flow sheets are used to record different types of data (e.g., vital signs, medication administration, nursing assessments). In computerized systems, this information is integrated and can be easily retrieved in various formats.
• Advantages. This integration reduces redundancy, minimizes the risk of errors, and ensures that all relevant data are available in a cohesive manner. Example: Instead of consulting separate charts for a patient’s vital signs, lab results, and medication history, a nurse can view all this information on a single digital interface.

Advantages and Disadvantages of Computerized Documentation

By replacing traditional paper-based methods with digital systems, healthcare providers can ensure more accurate, consistent, and accessible records. However, the adoption of computerized documentation comes with its own set of challenges.

The following outlines the various advantages and benefits associated with the integration and utilization of computerized documentation systems within healthcare settings:

1. Efficiency. Computerized systems streamline the documentation process, reducing the time needed for data entry and retrieval. This allows healthcare providers to focus more on direct patient care.

2. Accuracy and Consistency. Digital records minimize errors associated with manual documentation, such as illegible handwriting or misplaced charts. Standardized formats ensure consistency across the board.

3. Accessibility. Patient information can be accessed quickly from multiple locations, facilitating better coordination and continuity of care. This is especially beneficial in emergency situations or when consulting with specialists.

4. Enhanced Communication. Electronic health records improve communication among healthcare team members, as updates are made in real-time and are immediately available to all authorized personnel.

5. Data Security and Privacy. Modern computerized systems include robust security measures to protect patient data, ensuring compliance with regulations like HIPAA (Health Insurance Portability and Accountability Act).

Here are some of the disadvantages of computerized documentation:

1. Cost and Implementation. Initial setup costs for electronic systems can be high, and implementation requires significant time and resources. Training staff to use these systems effectively is also necessary.

2. Technical Issues. System downtimes, software glitches, and other technical issues can disrupt the documentation process and access to critical information.

3. Data Entry Burden. While digital systems aim to reduce redundancy, the need for thorough data entry can still be time-consuming and may contribute to clinician burnout if not managed properly.

4. Learning Curve. Healthcare providers need to be adequately trained to use computerized systems efficiently. A lack of proficiency can lead to errors or incomplete documentation.

7. Case Management

Case management is a coordinated approach to delivering high-quality, cost-effective healthcare within an established timeframe. This method focuses on optimizing patient outcomes and resource utilization, ensuring that care is both efficient and effective.

1. Emphasis on Quality and Cost-Effective Care

• Case management prioritizes the delivery of high-quality care that meets established standards while also being mindful of cost constraints. This approach ensures that patients receive the necessary care without unnecessary delays or expenses.
• Example: A case manager might coordinate care for a patient with chronic heart disease, ensuring they receive timely interventions, appropriate follow-up, and education on lifestyle changes to prevent readmissions, all while managing costs.

2. Established Length of Stay

• Care plans are designed to achieve specific health outcomes within a predetermined length of stay in the healthcare facility. This helps in controlling healthcare costs and improving bed availability for other patients.
• Example: For a patient undergoing knee replacement surgery , the case management plan would outline a typical hospital stay duration, including preoperative assessments, surgery , postoperative care, and rehabilitation, aiming to discharge the patient within a set timeframe.

3. Multidisciplinary Approach

• Case management involves a team of healthcare professionals from various disciplines working collaboratively to plan and document patient care. This ensures comprehensive care that addresses all aspects of the patient’s health needs.
• Example: The care team for a stroke patient might include doctors, nurses, physical therapists, occupational therapists, social workers, and dietitians, all contributing to a unified care plan.

4. Use of Critical Pathways

• Critical pathways are standardized, evidence-based plans that outline the essential steps in the care process for specific clinical conditions or procedures. These pathways guide the multidisciplinary team in delivering consistent and efficient care.
• Example: A critical pathway for managing a patient with pneumonia would include guidelines for diagnosis, antibiotic administration, patient monitoring, respiratory therapy, and discharge planning.

5. Managing Variances

• In case management, a variance refers to any deviation from the expected outcomes or established critical pathway. Identifying and addressing variances is crucial for maintaining the quality and effectiveness of care.
• Example: If a patient with pneumonia does not show expected improvement within the timeline set by the critical pathway, this would be noted as a variance. The care team would then investigate the cause (e.g., antibiotic resistance, comorbid conditions) and adjust the care plan accordingly.

Like any healthcare approach, case management is not without its challenges and limitations. While it offers numerous benefits, such as improved patient outcomes and enhanced efficiency, it also presents certain drawbacks, including implementation complexities, privacy concerns, and technological barriers.

The advantages of case management are multifaceted, encompassing improvements in patient outcomes, enhanced coordination among healthcare providers, and greater efficiency in resource utilization. The following are the advantages of case management approach in detail:

1. Holistic Patient Care. Case management documentation systems enable a comprehensive overview of a patient’s care journey, consolidating medical, social, and support services information into a single platform. This holistic approach promotes continuity of care and facilitates better-informed decision-making by healthcare professionals.

2. Efficiency and Coordination. By centralizing patient information, case management systems streamline communication and coordination among multidisciplinary healthcare teams. This can lead to improved efficiency in care delivery, reduced duplication of efforts, and smoother transitions between different care settings.

3. Resource Optimization. With enhanced visibility into patient needs and progress, case management documentation systems help optimize resource allocation. This includes better utilization of staff time, appropriate allocation of medical supplies and equipment, and optimization of financial resources by identifying cost-effective interventions.

4. Data-driven Insights. These systems often include reporting and analytics functionalities, allowing healthcare organizations to derive valuable insights from aggregated data. By analyzing trends, outcomes, and resource utilization patterns, organizations can identify areas for improvement, implement evidence-based practices, and enhance overall quality of care.

5. Compliance and Documentation Accuracy. Case management documentation systems facilitate compliance with regulatory requirements and accreditation standards by ensuring thorough and accurate documentation of patient assessments, interventions, and outcomes. This documentation not only supports legal and regulatory compliance but also strengthens the defense against potential litigation.

Here are some of the disadvantages of the case management approach in the documentation system:

1. Initial Implementation Challenges. Implementing a case management documentation system can be resource-intensive and disruptive to established workflows. Healthcare organizations may encounter resistance from staff members who are accustomed to traditional documentation methods, requiring comprehensive training and change management strategies to facilitate adoption.

2. Technical Issues and Integration Challenges. Technical problems such as system downtime, software glitches, and data interoperability issues can impede the smooth functioning of case management documentation systems. Integration with existing electronic health record (EHR) systems and other healthcare IT infrastructure components may also present challenges, potentially leading to data silos and inefficiencies.

3. Privacy and Security Concerns. Storing sensitive patient information in electronic format raises concerns about data privacy and security. Healthcare organizations must implement robust cybersecurity measures to protect against unauthorized access, data breaches, and other security threats. Compliance with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) is essential but requires ongoing vigilance and investment in cybersecurity resources.

4. User Interface Complexity. Complex user interfaces and cumbersome data entry processes can frustrate healthcare professionals and hinder productivity. Poorly designed systems may lead to documentation errors, incomplete records, and user dissatisfaction, undermining the intended benefits of case management documentation.

5. Risk of Data Overload. While case management documentation systems aim to provide comprehensive patient information, there is a risk of information overload. Clinicians may struggle to identify relevant data amidst a sea of extraneous information, potentially leading to cognitive overload, decision fatigue , and suboptimal clinical decision-making.

Documenting Nursing Activities

The client record must detail the client’s current condition and encompass the entirety of the nursing process . Regardless of the record-keeping system used by an agency, nurses document the nursing process through various forms within the clinical record.

Nursing Care Plan (NCP)

A nursing care plan (NCP) is a critical tool in healthcare that outlines the individualized care to be provided to a client. It serves as a roadmap for the nursing team, ensuring that all aspects of the client’s health are addressed in a systematic and organized manner. There are two primary types of Nursing Care Plans : Traditional Care Plans and Standardized Care Plans.

For the full guide, please see: Nursing Care Plan (NCP) Ultimate Guide

A Traditional Care Plan is tailored specifically for each client. It is detailed and personalized, addressing the unique needs of the individual. This type of care plan typically consists of three columns:

• Nursing Diagnoses. This column identifies the specific health problems or needs of the client. Each diagnosis is based on a thorough assessment and provides a foundation for the rest of the care plan.
• Expected Outcomes. Here, the desired results or goals of the nursing interventions are listed. These outcomes are specific, measurable, and time-bound, ensuring that they are achievable within a certain period. They provide a clear direction for nursing care and a way to evaluate progress.
• Nursing Interventions. This section outlines the actions that the nursing team will take to address the client’s needs and achieve the expected outcomes. Each intervention is evidence-based and tailored to the client’s specific situation, ensuring personalized and effective care.

A Standardized Care Plan, on the other hand, is developed based on an institution’s established standards of practice. These care plans are designed to ensure a high quality of care across the board, promoting consistency and efficiency within the healthcare facility. They are not individualized for each client but provide a general framework that can be adapted as needed. Key features include:

• Institutional Standards. The care plans reflect the best practices and protocols established by the healthcare institution. These standards are based on current evidence and guidelines in the nursing profession, ensuring that all clients receive care that meets a high level of quality.
• Consistency in Care. By using a standardized approach, nurses can provide consistent care to all clients, which is especially useful in larger healthcare settings where many nurses might be involved in a client’s care. This consistency helps in maintaining a uniform standard of care and reduces variability.
• Efficiency. Standardized care plans save time for the nursing staff, as they do not need to create a new plan from scratch for each client. Instead, they can use the pre-established plan as a base and modify it to fit the specific needs of the client, ensuring both thoroughness and efficiency.

A KARDEX is a widely used, concise method of organizing and recording data about a client, making essential information quickly accessible to all health professionals involved in the client’s care. The KARDEX system helps streamline communication and ensure continuity of care. Here’s an in-depth look at the KARDEX system:

The following are the features of the KARDEX system:

1. Concise and Comprehensive

The KARDEX provides a summary of important information about the client, including medical history, current diagnosis, treatments, medications, and nursing care plans . This concise format ensures that health professionals can quickly understand the client’s status and needs.

2. Accessible

The KARDEX system is designed to be easily accessible to all members of the healthcare team. Whether kept in a portable index file or on computer-generated forms, the KARDEX is available at a central location, ensuring that updated information is always at hand.

3. Organized Data

The KARDEX organizes client data in a structured manner. Information is typically divided into different sections or cards, each dedicated to a specific aspect of the client’s care. This organization helps health professionals quickly find and reference the information they need.

The following are the components of a KARDEX:

1. Client Identification . This section includes basic information such as the client’s name, age, gender, medical record number, and contact information.

2. Medical History . A brief overview of the client’s medical history, including past illnesses, surgeries, chronic conditions, and any known allergies.

3. Current Diagnosis and Treatment Plan. Information about the client’s current medical condition, including the primary diagnosis, secondary diagnoses, and the planned treatment or interventions. This section may also include the physician’s orders and the goals of treatment.

4. Medications. A detailed list of all medications the client is currently taking, including dosages, administration times, and routes of administration. This helps ensure accurate medication administration and avoids potential drug interactions.

5. Nursing Care Plan . Summarizes the nursing diagnoses, expected outcomes, and nursing interventions. This section aligns with the Traditional Care Plan approach, ensuring that nursing care is tailored to the client’s specific needs.

6. Daily Care and Activities. Information about the client’s daily routine, including dietary restrictions, mobility status, personal hygiene needs, and other activities of daily living (ADLs). This helps ensure that all aspects of the client’s daily care are addressed.

7. Progress Notes. A section for health professionals to document observations, changes in the client’s condition, and updates on the care plan. This ensures ongoing communication and continuity of care.

The following are the benefits of the KARDEX system:

1. Improved Communication. By providing a centralized and organized summary of client information, the KARDEX facilitates better communication among health professionals, leading to more coordinated and effective care.

2. Time Efficiency. The concise format of the KARDEX allows health professionals to quickly review and update client information, saving time compared to more detailed and lengthy documentation systems.

3. Enhanced Continuity of Care. The KARDEX helps ensure that all members of the healthcare team are aware of the client’s status and care plan, promoting consistent and continuous care even when multiple professionals are involved.

4. Portability. The portability of the KARDEX system, whether in physical card format or digital form, ensures that essential client information can be easily accessed in various clinical settings, enhancing flexibility and responsiveness in care delivery.

Nursing Discharge & Referral Summaries

Nursing discharge and referral summaries are essential documents completed when a client is being discharged from a healthcare facility or transferred to another institution or home setting. These summaries ensure that the client’s care continues seamlessly and that all relevant information is communicated to the next care provider or community health nurse. The summaries typically include comprehensive information about the client’s condition and care needs.

The following are the key components of Nursing Discharge & Referral Summaries:

1. Description of Client’s Physical, Mental & Emotional State. A detailed assessment of the client’s current health status, including physical conditions, mental health , and emotional well-being. This provides a baseline for the next care provider to understand the client’s overall health.

2. Resolved Health Problems. A list of health issues that have been successfully treated or managed during the client’s stay. This indicates progress made and treatments that have been effective.

3. Unresolved Continuing Health Problems. Documentation of any health issues that remain unresolved and require ongoing attention. This helps the next care provider prioritize and manage these conditions.

4. Treatments to be Continued. Detailed instructions on any treatments that need to be continued post-discharge, such as wound care , oxygen therapy , or other specific medical interventions. This ensures continuity in the client’s care regimen.

5. Current Medications. A comprehensive list of medications the client is currently taking, including dosages, frequencies, and administration methods. This information is crucial to avoid medication errors and ensure proper medication management.

6. Restrictions on Activity, Diet & Bathing. Specific instructions regarding any limitations the client must adhere to, such as restrictions on physical activity, dietary guidelines, and bathing precautions. These restrictions are critical for the client’s safety and recovery.

7. Functional/Self-Care Abilities. An assessment of the client’s ability to perform activities of daily living (ADLs) independently or with assistance. This includes mobility , personal hygiene , dressing , and feeding , providing a clear picture of the client’s self-care capabilities.

8. Comfort Level. Information about the client’s comfort and pain levels, including any pain management strategies that have been effective. This helps in maintaining the client’s comfort post-discharge.

9. Support Networks. Details about the client’s support system, including family, friends, or community resources that can assist in the client’s care. This support is crucial for the client’s well-being and recovery.

10. Client Education Provided. Documentation of the education given to the client about their disease process, self-care instructions, medication management, and lifestyle modifications. Ensuring the client understands their condition and care plan is vital for successful discharge.

11. Discharge Destination. The planned location where the client will be discharged, such as home, a rehabilitation center, or another healthcare facility. This information is essential for coordinating follow-up care and services.

12. Referral Services. Information about referrals to other services or specialists, such as a social worker, home health nurse, physical therapist, or other community resources. These referrals ensure that the client has access to the necessary support and follow-up care.

The following are the importance of nursing discharge and referral summaries in detail:

1. Continuity of Care. These summaries ensure that all pertinent information about the client’s health and care needs is communicated to the next care provider, facilitating a smooth transition and ongoing care.

2. Avoiding Readmission. By providing detailed information and clear instructions, these summaries help prevent complications that could lead to readmission.

3. Client Safety. Accurate and comprehensive discharge summaries help in identifying potential risks and providing strategies to mitigate them, enhancing client safety post-discharge.

4. Empowering Clients. Detailed education and clear instructions empower clients to manage their health effectively, promoting independence and self-care.

Guidelines for Good Documentation and Reporting

Effective documentation and reporting are foundational elements of nursing practice . Accurate and thorough records not only ensure high-quality patient care but also facilitate communication among healthcare providers, support clinical decision-making, and meet legal and regulatory requirements. These guidelines provide a framework for nurses to document and report client care in a consistent, clear, and comprehensive manner.

The primary objectives of these guidelines are to:

1. Enhance Communication. Ensure that all healthcare team members have access to the same accurate and current information about the patient’s condition, treatment, and care plans.

2. Improve Patient Safety. Provide a clear and comprehensive record that helps in identifying and addressing potential risks and errors in patient care.

3. Support Clinical Decision-Making. Offer detailed information that supports informed decision-making by nurses and other healthcare providers.

4. Ensure Legal Compliance. Maintain records that meet legal and regulatory standards, protecting both patients and healthcare providers.

5. Facilitate Quality Improvement. Provide data that can be used for continuous quality improvement initiatives and evidence-based practice.

To achieve these objectives, the following principles should be adhered to:

1. Fact . Information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells

2. Accuracy . Information must be accurate so that health team members have confidence in it

3. Completeness . The information within a record or a report should be complete, containing concise and thorough information about a client’s care. Concise data are easy to understand

4. Currentness . Ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following:

• Vital signs
• Administration of medications and treatments
• Preparation of diagnostic tests or surgery
• Change in status
• Admission, transfer, discharge or death of a client
• Treatment for a sudden change in status

5. Clarity. Use clear and concise language, avoiding jargon and abbreviations that may be misunderstood.

6. Legibility. Ensure that handwritten notes are legible and that electronic records are formatted consistently.

7. Organization . The nurse communicates in a logical format or order.

8. Confidentiality . A confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed

10 Tips on How Nurses Can Improve Documentation

Original article by M. Belleza, RN

One of the tasks that a nurse must accomplish for every shift is their documentation of the patient’s care . This is considered a legal document that can be used in every court of law.

From the traditional handwritten notes until today’s high technology hospital documentation, the important aspects should never be forgotten. Whether it is on paper or a computer, we have to endeavor that we should create a documentation that is reliable, accountable, and precise.

Here are some tips that would make your documentation a stand-out and an example among the rest.

Only chart findings you personally saw or witnessed. During assessment, only document what you heard, saw, or felt, only the hard facts to avoid bias. Subjective opinions are a no-no. If you are documenting something a patient said, it is best to document word for word or verbatim. Some patients may use abusive and foul language , but never include them in your documentation. You can describe the patient’s behavior instead. Never forget to document refusals to treatment, the patient’s reasons, and your actions. You would not want to be responsible for the injury of a patient who refused treatment but you forgot to document it. It might warrant a legal case against you.

Time is everything in the world of nursing. It gives you the power to control what could happen if you put time as your priority. Only document the procedures immediately after you have committed them. This may be a teeny bit hard to follow, especially if you handle more than two patients and you are up to your neck with work. But as much as possible, chart any findings and procedures close to the time after you have done it. Follow hospital protocol if you had a large gap between the executions of the procedure to the documentation.

Not all people are born with amazing handwriting. You may be one of those who are blessed with neat and straight handwriting, yet you may also belong to the ‘unfortunate’ ones who have handwriting that looks like chicken scratch. The only consideration for handwriting is their legibility. It must be readable no matter how disastrous the handwriting is. This would not be a problem for hospitals which have computerized charting systems, but for student nurses , you would be rotated at different facilities so you should be aware of how you chart.

You may want to document everything that happened step by step, but remember that you are not writing a novel. Be accurate with what you are including in your documentation and avoid putting in your opinion about the patient. A precise, short documentation would allow the next nurse to understand quickly what was done before her and would get the idea in a nutshell faster than you could blink your eye .

Any adverse reactions and events that occurred should be documented, pronto! However much we promote the safety of our patients, there are still incidents when the patient develops an allergy to food, medication, or environmental pollutants. Make sure to follow the policies and procedures of the hospital in documenting adverse effects on patients.

Most student nurses may have noticed a lot of abbreviated words when they check the chartings of the staff nurses. Many are confused because they have seen unfamiliar abbreviated terms and because staff nurses are somehow models to student nurses, they follow the same terms when they chart. Be aware of your abbreviations because there are standard abbreviations for medical terms and you cannot just make your own. Different healthcare facilities also have different abbreviations for certain terms, so be sure to check on the list of abbreviations before you venture in abbreviating for your charting. Improper abbreviated terms can be used against you in court if there is an issue regarding your care, and this is the point in our life that we should always, always avoid.

Your charting documents are considered legal papers; therefore, erasures should be avoided. This would be a point of suspicion in court. Make sure that what you are charting is right before you put it on paper. A neat and clean documentation is praiseworthy, and a little positive commendation is also food for the soul and the ego, and for your performance, of course.

The only color advisable to use in legal papers are either blue or black ink. And because your charting notes are legal papers, use these ink colors and nothing else. It also adds uniformity to you chartings. Remember, you are not scribbling on your notepads, so the use of any colored inks besides blue and black is definitely prohibited.

This pertains to following hospital standards and policies regarding proper chart documentation. Never institute your own policies, and never teach your colleagues on what to do if this is not a part of the hospital manual. Anything that you do on a legal premise could be used against you, and you would not want to lose your beloved license, right?

The entries you make on a charting should be confidential. It should not be shared to anyone, even your friends and families. Every patient is entitled to their dose of confidentiality, and a breach of this principle could also put you behind the bars.

As our journey towards the world of nursing progresses onwards, let us never forget the simple things that could make or break our career. Most of us may take documentation for granted, but it is part and parcel of who we are as nurses. These simple things are our stepping stones to a great career, and once we are used to doing things the best way possible, then it would stay the same and your career would be greater than you could ever have imagined.

• Berman, A., Snyder, S. J., & Frandsen, G. (2015). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th ed.) . Pearson.
• Roques, D. (2024). Source-Oriented Medical Record Format: Overview and FAQ. IntelyCare.

4 thoughts on “Documentation and Reporting in Nursing”

So much great information about charting, guidelines for documentation, nursing care plan, kardex and much more for grasp which is very educative and helps one to become successful in the nursing field.

Hello Barbara,

It’s fantastic to hear that you’re finding the information on charting and documentation so valuable! These are indeed cornerstone skills for success in nursing. By the way, is there a particular aspect of documentation or care planning you’d like to explore further? Or perhaps you have some tips on what’s been most helpful for you in grasping these concepts?

Keep up the great work in your nursing journey!

I would like to see a table that shows how to do in steps of diagnosis

Please check out our Nursing Diagnosis guide .

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Nursing Case Study Examples and Solutions

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NursingStudy.org is your ultimate resource for nursing case study examples and solutions. Whether you’re a nursing student, a seasoned nurse looking to enhance your skills, or a healthcare professional seeking in-depth case studies, our comprehensive collection has got you covered. Explore our extensive category of nursing case study examples and solutions to gain valuable insights, improve your critical thinking abilities, and enhance your overall clinical knowledge.

Comprehensive Nursing Case Studies

Discover a wide range of comprehensive nursing case study examples and solutions that cover various medical specialties and scenarios. These meticulously crafted case studies offer real-life patient scenarios, providing you with a deeper understanding of nursing practices and clinical decision-making processes. Each case study presents a unique set of challenges and opportunities for learning, making them an invaluable resource for nursing education and professional development.

• Nursing Case Study Analysis [10 Examples & How-To Guides] What is a case study analysis? A case study analysis is a detailed examination of a specific real-world situation or event. It is typically used in business or nursing school to help students learn how to analyze complex problems and make decisions based on limited information.
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Pediatric Nursing Case Studies

In this section, delve into the world of pediatric nursing through our engaging and informative case studies. Gain valuable insights into caring for infants, children, and adolescents, as you explore the complexities of pediatric healthcare. Our pediatric nursing case studies highlight common pediatric conditions, ethical dilemmas, and evidence-based interventions, enabling you to enhance your pediatric nursing skills and deliver optimal care to young patients.

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Mental health nursing plays a crucial role in promoting emotional well-being and providing care for individuals with mental health conditions. Immerse yourself in our mental health nursing case studies, which encompass a wide range of psychiatric disorders, therapeutic approaches, and psychosocial interventions. These case studies offer a holistic view of mental health nursing, equipping you with the knowledge and skills to support individuals on their journey to recovery.

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As the population ages, the demand for geriatric nursing expertise continues to rise. Our geriatric nursing case studies focus on the unique challenges faced by older adults, such as chronic illnesses, cognitive impairments, and end-of-life care. By exploring these case studies, you’ll develop a deeper understanding of geriatric nursing principles, evidence-based gerontological interventions, and strategies for promoting optimal health and well-being in older adults.

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Community health nursing plays a vital role in promoting health, preventing diseases, and advocating for underserved populations. Dive into our collection of community health nursing case studies, which explore diverse community settings, public health issues, and population-specific challenges. Through these case studies, you’ll gain insights into the role of community health nurses, interdisciplinary collaboration, health promotion strategies, and disease prevention initiatives.

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Critical care nursing demands swift decision-making, advanced technical skills, and the ability to provide intensive care to acutely ill patients. Our critical care nursing case studies encompass a range of high-acuity scenarios, including trauma, cardiac emergencies, and respiratory distress. These case studies simulate the fast-paced critical care environment, enabling you to sharpen your critical thinking skills, enhance your clinical judgment, and deliver exceptional care to critically ill patients.

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The field of maternal and child health nursing requires specialized knowledge and skills to support the health and well-being of women and children throughout their lifespan. Explore our collection of maternal and child health nursing case studies, which encompass prenatal care, labor and delivery, postpartum care, and pediatric nursing. These case studies provide a comprehensive view of maternal and child health, allowing you to develop expertise in this essential area of nursing practice.

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Surgical nursing involves caring for patients before, during, and after surgical procedures. Our surgical nursing case studies cover a wide range of surgical specialties, including orthopedics, cardiovascular, and gastrointestinal surgeries. Delve into these case studies to gain insights into preoperative assessment, perioperative management, and postoperative care. By examining real-life surgical scenarios, you’ll develop a comprehensive understanding of surgical nursing principles and refine your skills in providing exceptional care to surgical patients.

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Nursing leadership is essential for driving positive change and ensuring high-quality patient care. Our nursing leadership case studies examine effective leadership strategies, change management initiatives, and interprofessional collaboration in healthcare settings. Gain insights into the qualities of successful nurse leaders, explore innovative approaches to leadership, and learn how to inspire and motivate your team to achieve excellence in nursing practice.

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Remember, success in nursing begins with knowledge and continues with lifelong learning. Explore our nursing case study examples and solutions today and embark on a journey of professional growth and excellence.

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

• Hardcopy Version at National Academies Press

The decade ahead will test the nation’s nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. In the decade since the prior The Future of Nursing report was issued by the Institute of Medicine, the world has come to understand the critical importance of health to all aspects of life, particularly the relationship among what are termed social determinants of health (SDOH), health equity, and health outcomes. In a year that was designated to honor and uplift nursing (the International Year of the Nurse and the Midwife 2020), nurses have been placed in unimaginable circumstances by the COVID-19 pandemic. The decade ahead will demand a stronger, more diversified nursing workforce that is prepared to provide care; promote health and well-being among nurses, individuals, and communities; and address the systemic inequities that have fueled wide and persistent health disparities.

The vision of the Committee on the Future of Nursing 2020–2030, which informs this report, is the achievement of health equity in the United States built on strengthened nursing capacity and expertise. By leveraging these attributes, nursing will help to create and contribute comprehensively to equitable public health and health care systems that are designed to work for everyone. To achieve health equity, the committee also envisions a major role for the nursing profession in engaging in the complex work of aligning public health, health care, social services, and public policies to eliminate health disparities and achieve health equity. Specifically, with implementation of this report’s recommendations, the committee envisions 10 outcomes that position the nursing profession to contribute meaningfully to achieving health equity (see Box S-1 ).

Achieving Health Equity Through Nursing: Desired Outcomes.

• HEALTH AND HEALTH INEQUITIES

Health inequities, defined as “systematic differences in the opportunities that groups have to achieve optimal health, leading to unfair and avoidable differences in health outcomes,” disproportionately impact people of color; the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community; people with disabilities; those with low income; and those living in rural areas. Indeed, growing evidence reveals a clear association between inequities in both health and access to health care and SDOH—the conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDOH include both the positive and negative aspects of these conditions. Examples of SDOH include education, employment, health systems and services, housing, income and wealth, the physical environment, public safety, the social environment (including structures, institutions, and policies), and transportation. Everyone is affected by SDOH. Some people who have more education or higher incomes will fare better healthwise as they may be able to make more informed choices, have better opportunities to access health care, and have the means to pay for health care. Others, without the benefit of these positive social determinants, are unlikely to fare as well.

A related concept is social needs —individual-level, nonmedical, acute resource needs for such things as housing, reliable transportation, and a strong support system at home that are necessary for good health outcomes and health equity. Health equity can be advanced at the individual level by addressing these needs and at the population level by addressing SDOH. Health equity benefits all individuals by promoting such macrostructural benefits as economic growth, a healthier environment, and national security.

For too long, the United States has overinvested in treating illness and underinvested in promoting health and preventing disease. The nation has spent more on medical care than any other high-income country, yet it has seen consistently worse health outcomes than those of its peer countries, including the lowest life expectancy, more chronic health conditions, and the highest rates of infant mortality. At the same time, the COVID-19 pandemic has starkly revealed Americans’ unequal access to opportunities to live a healthy life, often resulting from entrenched structural and systemic barriers that include poverty, racism, and discrimination. These two phenomena—suboptimal health outcomes and inequities in health and health care—are not unrelated. If the nation is to achieve better population health, it will have to meet the challenge of mitigating these inequities. Herein lies the greatest contribution of the nursing workforce in the decade ahead.

• THE ROLE OF NURSES IN ADVANCING HEALTH EQUITY

A nation cannot fully thrive until everyone—no matter who they are, where they live, or how much money they make—can live the healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Whether in a school, a hospital, or a community health clinic, they have worked to address the root causes of poor health. The history of nursing is grounded in social justice and community health advocacy. The Code of Ethics for Nurses with Interpretive Statements from the American Nurses Association (ANA), for example, obligates nurses to “integrate principles of social justice into nursing and health policy.” 2

Nurses work in a wide array of settings and practice at a range of professional levels. They often act as the first and most frequent line of contact with people of all backgrounds and experiences seeking care. The nursing workforce also represents the largest of the health care professions—nearly four times the size of the physician workforce. In their various capacities and given their numbers, nurses are uniquely positioned to manage teams and link clinical care, public health, and social services.

• STUDY PURPOSE AND APPROACH

Nurses, then, have a critical role to play in achieving the goal of health equity. But to take on the pursuit of that goal, they need robust education, supportive work environments, and autonomy. Accordingly, the Robert Wood Johnson Foundation asked the National Academies of Sciences, Engineering, and Medicine to conduct a study aimed at charting a path forward for the nursing profession to help create a culture of health and reduce disparities in people’s ability to achieve their full health potential. To carry out this study, the National Academies convened an ad hoc committee of 15 experts in the fields of nursing leadership, education, practice, and workforce, as well as health policy, economics and health care finance, informatics, population health and health disparities, health care quality and delivery, and health care research and interventions.

To supplement the knowledge and expertise of its members, the committee solicited input from additional experts and interested members of the public at two public sessions held in conjunction with committee meetings. Further input came from several site visits that included town hall meetings. In addition, the committee reviewed the salient peer-reviewed and grey literature not associated with commercial publishers, carried out original data analyses, commissioned papers on topics of particular relevance, and considered public and organizational statements pertinent to this study.

To organize and consolidate this wealth of information, the committee developed the framework depicted in Figure S-1 . This framework structures the report’s discussion of the key areas for strengthening the nursing profession to meet the challenges of the decade ahead. The heart of this framework is the key areas shown at the top of the figure: the nursing workforce, leadership, nursing education, nurse well-being, and emergency preparedness and response, and the responsibilities of nursing with respect to structural and individual determinants of health. Nurses play multiple roles in acute, community, and public health settings that include, but are not limited to, care team member and leader, primary care provider, patient and family advocate, population health coordinator, educator, public health professional, health systems leader, organizational and public policy maker, researcher and scientist, and informaticist. Through each of these roles, nurses impact the medical and social factors that drive health outcomes and health and health care equity. Nurses can address SDOH through interventions at both the individual level (e.g., referring an individual’s family to a food assistance program) and the structural level (e.g., alleviating the problem of food insecurity in the community). Similarly, nurses can address medical determinants of health at both the individual level (e.g., providing patient education and medication management) and the structural level (e.g., implementing a system of team-based multisector care that includes coordination of care across settings and sectors).

A framework for understanding the nurse’s role in addressing the equity of health and health care. * Examples of nursing roles in acute, community, and public health settings include care coordinator, policy maker, clinician, educator, researcher/scientist, (more...)

• ACTING NOW TO IMPROVE THE HEALTH AND WELL-BEING OF THE NATION

The health and well-being of the nation are at an inflection point. In the decade ahead, in addition to growth in the overall size of the U.S. population, other sociodemographic factors and health workforce imbalances will increase the demand for nurses, particularly in areas in which the current registered nurse (RN) and advanced practice registered nurse (APRN) workforce is inadequate to meet the nation’s health care needs. For instance, a 2020 report prepared for the American Association of Medical Colleges estimated that by 2033, current physician shortages, seen particularly in the areas of primary care, mental health, and gerontology and in rural areas, could increase—for primary care physicians, ranging between 21,400 and 55,200, and for non–primary care specialty physicians, between 33,700 and 86,700. Salient sociodemographic factors include the aging population, the increasing incidence of mental and behavioral health conditions, increases in lack of access to primary health care, persistently high maternal mortality rates, and worsening physician shortages. For example, the aging of the U.S. population means that over this decade, increasing numbers of people will age into their 70s, 80s, 90s, and beyond. In 2030, 73.1 million people, or 21 percent of the U.S. population, will be older than 65—a population that typically presents with morbidities at higher rates than are seen in younger people.

The strengths of the nursing workforce are many, yet they will be tested by formidable challenges that are already beginning to affect nurses and the health systems and organizations in which they work. These challenges will arise not only from the above changes occurring throughout the broader society but also from changes within the health care system itself and within the nursing and larger health care workforce. Further challenges for nursing will arise from health-related public policies and other factors that affect the scope of practice, size, distribution, diversity, and educational preparation of the nursing workforce. These many challenges include the need to

• increase the number of nurses available to meet the nation’s growing health care needs;
• rightsize the clinical specialty distribution of nurses;
• increase the distribution of nurses to where they are needed most;
• ensure a nursing workforce that is diverse and prepared with the knowledge and skills to address SDOH;
• overcome current and future barriers affecting workforce capacity; and
• anticipate long-term impacts of the COVID-19 pandemic on the nursing workforce.

Conclusion 3-1: A substantial increase in the numbers, types, and distribution of members of the nursing workforce and improvements in their knowledge and skills in addressing social determinants of health are essential to filling gaps in care related to sociodemographic and population factors. These factors include the aging population, the increasing incidence of mental and behavioral health conditions, and the increasing lack of access to primary and maternal health care.

Access to comprehensive health services is an essential precursor to equitable, high-quality health care. Nurses can help advance health care equity and improve health outcomes by assisting people in navigating the health care system, providing close monitoring and follow-up across the care continuum, focusing care on the whole person, and providing care that is appropriate and shows cultural humility. 3 In the current system, care is often disjointed. Nurses can provide care management that helps ensure seamless care, serve as advocates for patients and communities, and assist in increasing individuals’ trust in and engagement with the health care system.

Lifting Barriers to Expand the Contributions of Nursing

Nurses can address SDOH and help improve health equity by providing care management and team-based care; expanding the capacity of primary care, including maternal and pediatric care, mental health care, and telehealth; and providing care in school, home, work, and public health settings. Yet, their ability to fulfill this potential is limited by state-level regulations restricting nurse practitioners’ (NPs’) scope of practice. While considerable progress has been made over the past two decades in lifting such regulations, 27 states still do not allow full practice authority for NPs. As of January 2021, 23 states and the District of Columbia allowed full practice authority for NPs, permitting them to prescribe medication, diagnose patients, and provide treatment without the presence of a physician. In 16 states, NPs need a physician’s authority to prescribe medication, and in 11 states, they require physician oversight for all practice.

Conclusion 3-2: Eliminating restrictions on the scope of practice of advanced practice registered nurses and registered nurses so they can practice to the full extent of their education and training will increase the types and amount of high-quality health care services that can be provided to those with complex health and social needs and improve both access to care and health equity.

Designing Better Payment Models

How care is paid for can directly influence access to care. The design of payment systems influences what health care is provided to individuals and communities, where care is provided, and by whom. Positioning health systems to work in partnership with other sectors to meet the complex health and social needs of individuals can help reduce health inequities. However, current payment systems are not designed to pay for services—including those provided by nurses, such as supporting team-based care and advancing proven interventions and strategies for reducing health disparities—that address social needs and SDOH. Going forward, payment systems need to be redesigned to recognize the value of those services.

Nurses are essential to whole-person care through their vital roles in coordinating and managing care, helping people navigate the health care system, and providing health education, as well as addressing SDOH and advancing health equity. By supporting team-based care, improved communication, and proven interventions and strategies that can reduce health disparities, payment systems can enable nurses to make these essential contributions to improving care and outcomes for all patients.

Conclusion 6-3: Payment mechanisms need to be designed to support the nursing workforce and nursing education in addressing social needs and social determinants of health in order to improve population health and advance health equity.

New payment models, such as accountable care organizations (ACOs), accountable health communities (AHCs), and value-based payment (VBP), can give health care organizations the flexibility to pursue these goals. Changing the ways in which the nation pays for health care will cause discomfort among some, but will also stimulate those seeking innovative ways of maximizing the population’s health. Payment reform represents an opportunity to consider who has access to health care and who does not, what types of services are needed to improve individual and population health, and how the nation’s resources can be used most wisely to these ends.

Strengthening Nursing Education

Nursing education needs to be markedly strengthened to prepare nurses to identify and act on the complex social, economic, and environmental factors that influence health and well-being. In particular, their education needs to provide nursing students with substantive, diverse, and sustained community-based experiences, as well as to substantially reorient curricula and reevaluate hiring and admission practices so as to achieve a diverse faculty and student population.

Nursing organizations have developed guidelines for how nursing education should prepare nurses to address health equity issues and SDOH in a meaningful way. The American Association of Colleges of Nursing’s (AACN’s) Essentials provides an outline for the necessary curriculum content and expected competencies for graduates of baccalaureate, master’s, and doctor of nursing practice (DNP) programs. Yet, despite this guidance and the numerous calls to incorporate equity, population health, and SDOH into undergraduate and graduate nursing education, these and related concepts are currently not well integrated into nursing curricula.

Conclusion 7-1: A curriculum embedded in coursework and experiential learning that effectively prepares students to promote health equity, reduce health disparities, and improve the health and well-being of the population will build the capacity of the nursing workforce.

Nursing is increasingly practiced in community settings, such as schools and workplaces, as well as through home health care and public health clinics. Other innovative care delivery models are situated in libraries and homeless shelters and implemented through telehealth visits. Nursing students are prepared to practice in hospitals, but do not necessarily receive the same level of training and preparation for community and telehealth settings. Education in the community allows nursing students to learn about the broad range of care environments and to work collaboratively with other professionals who work in these environments, including those from nonhealth sectors.

Conclusion 7-3: Learning experiences that develop nursing students’ understanding of health equity, social determinants of health, and population health and prepare them to incorporate that understanding into their professional practice include opportunities to learn cultural humility and recognize one’s own implicit biases; gain experience with interprofessional collaboration and multisector partnerships to enable them to address social needs comprehensively and drive structural improvements; develop such technical competencies as use of telehealth, digital health tools, and data analytics; and gain substantive experience with delivering care in diverse community settings, such as public health departments, schools, libraries, workplaces, and neighborhood clinics.

Building a diverse nursing workforce is a critical part of preparing nurses to address SDOH and health equity. While the nursing workforce has steadily grown more diverse, nursing schools need to continue and expand their efforts to recruit and support diverse students that reflect the populations they will serve.

Conclusion 7-4: Successfully diversifying the nursing workforce will depend on holistic efforts to support and mentor/sponsor students and faculty from a wide range of backgrounds, including cultivating an inclusive environment; providing economic, social, professional, and academic supports; ensuring access to information on school quality; and minimizing inequities.

Valuing Community Nursing

School and public health nurses play a vital role in advancing health equity. Adequate funding for these nurses is essential if they are to take on that role. School nurses are front-line health care providers, serving as a bridge between the health care and education systems and other sectors. Whether they are hired by school districts, health departments, or hospitals, school nurses focus on the physical and mental health of students in the context of educational environments. They serve as both essential care providers for individuals and links to broader community health issues through the student populations they serve.

School nurses are a particularly critical resource for students experiencing such challenges as food insecurity, homelessness, and living in impoverished circumstances, for whom the school nurse may be the only health care professional they see regularly. Accordingly, access to a school nurse is a health care equity issue for some students, especially in light of the increasing number of students who have complex health needs. School nurses also are well positioned to work with students and families in their neighborhoods and homes to address individual and family social needs, such as access to care, healthy food, and safe and healthy environments/neighborhoods. More school nurses need the practice authority to address in creative ways the complex health and social needs of the populations they serve.

Likewise, the COVID-19 pandemic has highlighted the pivotal role of nurses in improving health care equity. During the pandemic, public health and hospital nurses have had to work synergistically both to help flatten the infection curve and support mitigation strategies (public health nurses) and to care for the sick and critically ill (inpatient and intensive care unit [ICU] nurses). The pandemic also has heightened the need for team-based care, infection control, person-centered care, and other skills that reflect the strengths of community nurses.

Fostering Nurses’ Roles as Leaders and Advocates

Creating a future in which opportunities to optimize health are more equitable will require disrupting the deeply entrenched prevailing paradigms of health care, which in turn will require enlightened, diverse, courageous, and competent leadership. Nurses have always been key to the health and well-being of patients and communities, but a new generation of nurse leaders is now needed—one that recognizes the importance of diversity and is able to use and build on the increasing evidence base supporting the link between SDOH and health status. Today’s nurses are called on to lead in the development of effective strategies for improving the nation’s health with due attention to the needs of the most underserved individuals, neighborhoods, and communities and the crucial importance of advancing health equity. Implementing change to address SDOH and advance health equity will require the contributions of nurses in all roles and all settings; although no one nurse can successfully implement change without the collaboration of others. In addition to collaboration among members of the nursing profession, the creation of enduring change will require the involvement of patients and community members. Rather than a more hierarchal system of leadership, moreover, collaborative leadership assumes that everyone involved has unique contributions to make and that constructive dialogue and joint resources are needed to achieve ongoing goals.

Conclusion 9-1: Nurse leaders at every level and across all settings can strengthen the profession’s long-standing focus on social determinants of health and health equity to meet the needs of underserved individuals, neighborhoods, and communities and to prioritize the elimination of health inequities.

Racism and discrimination are deeply entrenched in U.S. society and its institutions, and the nursing profession is no exception. Nurse leaders can play an important role in acknowledging the history of racism within the profession and in helping to dismantle structural racism and mitigate the effects of discrimination and implicit bias on health. If they are to take on this role, it will be essential to build a more diverse nursing workforce and support nurses of diverse backgrounds in pursuing leadership roles.

Conclusion 9-4: Nurse leaders have a responsibility to address structural racism, cultural racism, and discrimination based on identity (e.g., sexual orientation, gender), place (e.g., rural, urban), and circumstances (e.g., disability, mental health condition) within the nursing profession and to help build structures and systems at the societal level that address these issues to promote health equity.

Preparing Nurses to Respond to Disasters

The increasing frequency of natural and environmental disasters and public health emergencies, such as the COVID-19 pandemic, reveals in stark detail the critical importance of having a national nursing workforce prepared with the knowledge, skills, and abilities to respond to these events. COVID-19 has revealed deep chasms within an already fragmented U.S. health care system, resulting in significant excess mortality and morbidity, glaring health inequities, and the inability to contain a rapidly escalating pandemic. Most severely—and unfairly—affected are individuals and communities of color, who suffer from the compound disadvantages of racism, poverty, workplace hazards, limited health care access, and preexisting health conditions resulting from the foregoing factors. As other disasters and public health emergencies threaten population health in the decades ahead, articulation of the roles and responsibilities of nurses in disaster response and public health emergency management will be critical to the nation’s capacity to plan for and respond to these types of events.

Conclusion 8-2: A bold and expansive effort, executed across multiple platforms, will be needed to fully support nurses in becoming prepared for disaster and public health emergency response. It is essential to convene experts who can develop a national strategic plan articulating the existing deficiencies in this regard and action steps to address them, and, most important, establishing where responsibility will lie for ensuring that those action steps are taken.

Supporting the Health and Well-Being of Nurses

Nurses’ health and well-being are affected by the demands of their workplace, and in turn affect the quality and safety of the care they provide. Thus, it is essential to address the systems, structures, and policies that create workplace hazards and stresses that lead to burnout, fatigue, and poor physical and mental health among the nursing workforce. With the emergence of COVID-19, the day-to-day demands of nursing have been both illuminated and exacerbated. Nurses are coping with unrealistic workloads; insufficient resources and protective equipment; risk of infection; stigma directed at health care workers; and the mental, emotional, and moral burdens of caring for patients with a new and unpredictable disease and helping with contact tracing and testing. Moreover, if nurses are to contribute to addressing the many social determinants that influence health, they must first feel healthy, well, and supported themselves. Policy makers, employers of nurses, nursing schools, nurse leaders, and nursing associations all have a role to play to this end.

Conclusion 10-1: All environments in which nurses work affect the health and well-being of the nursing workforce. Ultimately, the health and well-being of nurses influence the quality, safety, and cost of the care they provide, as well as organizations and systems of care. The COVID-19 crisis has highlighted the shortcomings of historical efforts to address nurses’ health and well-being.

• RECOMMENDATIONS

The committee’s recommendations (see Box S-2 ) call for change at both the individual and system levels, constituting a call for action to the nation’s largest health care workforce, including nurses in all settings and at all levels, to listen, engage, deeply examine practices, collect evidence, and act to move the country toward greater health equity for all. The committee’s recommendations also are targeted to the actions required of policy makers, educators, health care system leaders, and payers to enable these crucial changes.

The Committee’s Recommendations.

• FINAL THOUGHTS

In conclusion, the nation will never fully thrive until everyone can live the healthiest possible life. Promoting health and well-being has always been nurses’ business. Thus, it is essential to harness the vast expertise and untapped potential of nurses at every level and in every setting to build healthy communities for all. As evidenced in this report, nurses are bridge builders and collaborators who engage and connect with people, communities, and organizations to promote health and well-being. But they need ongoing support from the systems that educate, train, employ, and enable them to advance health equity. As of this writing, the COVID-19 pandemic has starkly revealed the challenges nurses face every day. But this crisis has also given some nurses more autonomy, shifted payment models, and sparked overdue conversations about dismantling racism in health care. Policy makers and system leaders must seize this moment to support, strengthen, and transform the largest segment of the health care workforce so nurses can help chart the nation’s course to good health and well-being for all. Over the course of this decade, nurses will face a host of challenges—from addressing the lasting effects of COVID-19 on themselves and their communities to dismantling the racist systems that create and perpetuate inequities. No one is immune from hate and bigotry, but everyone has the capacity for empathy, understanding, and solidarity in a shared hope for a more just and equitable world. The nursing profession is resilient and well positioned to help usher in a new era in which everyone has a chance to live the healthiest possible life.

This Summary does not include references. Citations for the discussion presented in the Summary appear in the subsequent report chapters.

See https://www ​.nursingworld ​.org/practice-policy ​/nursing-excellence ​/ethics/code-of-ethics-fornurses ​/coe-view-only (accessed April 13, 2021).

Cultural humility is “defined by flexibility; awareness of bias; a lifelong, learning-oriented approach to working with diversity; and a recognition of the role of power in health care interactions.”

• Cite this Page National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. Summary.
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For assignments to be successful, you need to determine the needs of both nurses and patients. Nursing assignments, usually help to determine the daily activities of the nurses, the patient meets and assessments, coordinate different shifts and maintain a specific length of working hours. To meet this challenge of preparing nursing assignment sheets , you can take the assistance of sheet templates and learn the process eventually.

Step 1: Gather Information

Step 2: determine the process, step 3: set shift priorities, step 4: evaluating success, step 5: keep updating.

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3.3 Assignment

Nursing team members working in inpatient or long-term care settings receive patient assignments at the start of their shift. Assignment refers to routine care, activities, and procedures that are within the legal scope of practice of registered nurses (RN), licensed practical/vocational nurses (LPN/VN), or assistive personnel (AP). [1] Scope of practice for RNs and LPNs is described in each state’s Nurse Practice Act. Care tasks for AP vary by state; regulations are typically listed on sites for the state’s Board of Nursing, Department of Health, Department of Aging, Department of Health Professions, Department of Commerce, or Office of Long-Term Care. [2]

See Table 3.3a for common tasks performed by members of the nursing team based on their scope of practice. These tasks are within the traditional role and training the team member has acquired through a basic educational program. They are also within the expectations of the health care agency during a shift of work. Agency policy can be more restrictive than federal or state regulations, but it cannot be less restrictive.

Patient assignments are typically made by the charge nurse (or nurse supervisor) from the previous shift. A charge nurse is an RN who provides leadership on a patient-care unit within a health care facility during their shift. Charge nurses perform many of the tasks that general nurses do, but also have some supervisory duties such as making assignments, delegating tasks, preparing schedules, monitoring admissions and discharges, and serving as a staff member resource. [3]

Table 3.3a. Nursing Team Members’ Scope of Practice and Common Tasks [4]

An example of a patient assignment is when an RN assigns an LPN/VN to care for a client with stable heart failure. The LPN/VN collects assessment data, monitors intake/output throughout the shift, and administers routine oral medication. The LPN/VN documents this information and reports information back to the RN. This is considered the LPN/VN’s “assignment” because the skills are taught within an LPN educational program and are consistent with the state’s Nurse Practice Act for LPN/VN scope of practice. They are also included in the unit’s job description for an LPN/VN. The RN may also assign some care for this client to AP. These tasks may include assistance with personal hygiene, toileting, and ambulation. The AP documents these tasks as they are completed and reports information back to the RN or LPN/VN. These tasks are considered the AP’s assignment because they are taught within a nursing aide’s educational program, are consistent with the AP’s scope of practice for that state, and are included in the job description for the nursing aide’s role in this unit. The RN continues to be accountable for the care provided to this client despite the assignments made to other nursing team members.

Special consideration is required for AP with additional training. With increased staffing needs, skills such as administering medications, inserting Foley catheters, or performing injections are included in specialized training programs for AP. Due to the impact these skills can have on the outcome and safety of the client, the National Council of State Board of Nursing (NCSBN) recommends these activities be considered delegated tasks by the RN or nurse leader. By delegating these advanced skills when appropriate, the nurse validates competency, provides supervision, and maintains accountability for client outcomes. Read more about delegation in the “ Delegation ” section of this chapter.

When making assignments to other nursing team members, it is essential for the RN to keep in mind specific tasks that cannot be delegated to other nursing team members based on federal and/or state regulations. These tasks include, but are not limited to, those tasks described in Table 3.3b.

Table 3.3b. Examples of Tasks Outside the Scope of Practice of Nursing Assistive Personnel

As always, refer to each state’s Nurse Practice Act and other state regulations for specific details about nursing team members’ scope of practice when providing care in that state.

Find and review Nurse Practice Acts by state at https://www.ncsbn.org/policy/npa.page .

Read more about the Wisconsin’s Nurse Practice Act and the standards and scope of practice for RNs and LPNs at Wisconsin’s Legislative Code Chapter N6.

Read more about scope of practice, skills, and practices of nurse aides in Wisconsin at DHS 129.07 Standards for Nurse Aide Training Programs.

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation . https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf ↵
• McMullen, T. L., Resnick, B., Chin-Hansen, J., Geiger-Brown, J. M., Miller, N., & Rubenstein, R. (2015). Certified nurse aide scope of practice: State-by-state differences in allowable delegated activities. Journal of the American Medical Directors Association, 16 (1), 20–24. https://doi.org/10.1016/j.jamda.2014.07.003 ↵
• RegisteredNursing.org. (2021, April 13). What is a charge nurse? https://www.registerednursing.org/specialty/charge-nurse/ ↵
• RegisteredNursing.org. (2021, January 27). Assignment, delegation and supervision: NCLEX-RN. https://www.registerednursing.org/nclex/assignment-delegation-supervision/ ↵
• State of Wisconsin Department of Health Services. (2018). Medication administration by unlicensed assistive personnel (UAP): Guidelines for registered nurses delegating medication administration to unlicensed assistive personnel. https://www.dhs.wisconsin.gov/publications/p01908.pdf ↵

Routine care, activities, and procedures that are within the authorized scope of practice of the RN, LPN/VN, or routine functions of the assistive personnel.

Making adjustments to medication dosage per an established protocol to obtain a desired therapeutic outcome.

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Care of a Confused Patient

Last modified: 9th Jun 2021

The client in this example has been diagnosed with Stage 4 Lung Cancer (T4, N3) which denotes that she suffers from a malignant tumour which has invaded the oesophagus, epicardium, pleural cavity, T5 and T6 vertebrae with Metastasis to the supraclavicular lymph node. She also suffers from osteoarthritis of L2-L5 and S1-S5, Type 2 Diabetes and Psoriasis....

Review of Health Insurance Portability and Accountability Act (HIPAA)

This research paper entails how technological advancement has played a huge role in healthcare and how social media can pose a huge impact on maintaining patient’s privacy by nurses. Gagnon and Sabus (2015) reported that in 2014 a report from Mayo clinic shows that 1,500 U.S hospitals manage about 6,500 social media accounts on Twitter, Facebook, YouTube, and LinkedIn....

Rehabilitation of Stroke Patients

Last modified: 26th May 2021

Affecting nearly 795,000 patients in the United States each year, stroke is one of the leading causes of people, mostly adults, with long-term disability....

Essay on Intrapartum Care

Last modified: 23rd Apr 2021

This assignment examines factors that influence the decision making of expecting parents in relation to the preferred place of birth, if there is higher intervention rates in the intrapartum period depending on the chosen place of birth and the significant role of relationship and support during the intrapartum period in the location of birth....

Assessment On Support Needs In The Elderly

Last modified: 9th Apr 2021

In this assessment, we are tasked to recognize and carefully look into the support needs of older adults suffering from geriatric health conditions most especially those with dementia....

A Critical Appraisal of the Giving Up Smoking in Pregnancy Initiative

Last modified: 8th Apr 2021

The object of this assignment is to critically appraise a health promotion initiative related to midwifery practice. The initiative chosen is a NHS Health Scotland leaflet entitled ‘Smoking: giving up during pregnancy: a guide for pregnant women who want to stop smoking’...

Protecting the Public and Maintaining Care Standards: The Nursing and Midwifery Council

Last modified: 25th Feb 2021

In this article, the speaker will start by addressing the Nursing and Midwifery Council (NMC)'s key roles , which they seek to protect patients and service users as well as improve standards of care across the UK....

Care Planning for Adolescent Patient

AC 1.1   Explain the job role in relation to your patient. What exactly will they do and why? Tanisha, Tanisha, 16, has been waiting with a friend to be seen. She hurt her wrist at the local skate p...

Professional Values, Nursing and Decision Making in Clinical Environment

Last modified: 8th Feb 2021

The assignment will discuss my personal experiences in depth, alongside a range of published literature to support and enable me to elaborate on my points....

Factors for Communication in Nursing

Last modified: 6th Jan 2021

Communication is paramount in nursing as it plays an essential part of the nursing practice, with significant meaning...

Work Practice Review of Geriatric Residential Care Facility

Last modified: 21st Dec 2020

Gibbs’ (1988) reflective cycle is a popular model for reflection. In this assignment I’m going to use this in assignment work placement review....

Examples Of Acute Injuries Health And Social Care Essay

Last modified: 10th Dec 2020

To be fit and healthy it is important that you exercise, however, exercise too much and you could injure yourself. ...

Healthcare Supply Chain Management

Last modified: 4th Dec 2020

The paper report methods used in healthcare area that result in well-organized SCM practices. Mixing and concentration helps in merging of all work courses in one set of criteria methods using normal product code shared with all processes....

A Critical Analysis of Patient-centred Assessment Including a Reflective Analysis Simulated Problem Focused Assessment

Richard and Whyte (2011), report that patient-centred practice is acknowledged to be a fundamental component of individual sessions between patients and healthcare professionals....

Pathophysiology of Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD) is chronic inflammation of the air ways, specifically the peripheral airways and lung parenchyma (alveoli and bronchioles) which leads to expiratory airflow limitation....

Personal Theoretical Framework for Advanced Practice Nursing

Last modified: 3rd Dec 2020

Self-care pertains to the person’s activities to maintain and sustain health and wellbeing. These are the activities one does regularly such as eating, bathing, dressing, grooming, relaxation, sleeping....

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