110_Module 4

A set of care guidelines that outline the course of treatment and the recommended interventions

that should be implemented to achieve optimal results.

These are common tools found in case management systems

• Nursing Plan

• Nursing Care Plan

• Traditional Care Plan

• Standardized Care Plan

A care guideline written specifically for each patient

• Nursing Plan

• Nursing Care Plan

• Traditional Care Plan

• Standardized Care Plan

A care guideline based on an institution’s standards of practice; helps to provide a

high quality

• Nursing Plan

• Nursing Care Plan

• Traditional Care Plan

• Standardized Care Plan

a guideline for good documentation and reporting that states:

Information about clients and their care must be

factual.

• Facts

• Accuracy

• Completeness

• Up-to-date/Currentness

• Organization

a guideline for good documentation and reporting that states:

A record should contain descriptive, objective

information about what a nurse sees, hears, feels

and smells.

• Facts

• Accuracy

• Completeness

• Up-to-date/Currentness

• Organization

a guideline for good documentation and reporting that states:

Information must be accurate so that health team

members have confidence in it.

• Facts

• Accuracy

• Completeness

• Up-to-date/Currentness

• Organization

a guideline for good documentation and reporting that states:

The information within a record or a report should

be complete, containing concise and thorough

information about a client’s care.

• Facts

• Accuracy

• Completeness

• Up-to-date/Currentness

• Organization

a guideline for good documentation and reporting that states:

Concise data are easy to understand

• Facts

• Accuracy

• Completeness

• Up-to-date/Currentness

• Organization

a guideline for good documentation and reporting that states:

Ongoing decisions about care must be based on

currently reported information.

• Facts

• Accuracy

• Completeness

• Up-to-date/Currentness

• Organization

a guideline for good documentation and reporting that states:

The nurse communicate and organized entry in a

logical format or order.

• Facts

• Accuracy

• Completeness

• Organization

• Confidentiality