Patient-centered care procedures

1) Continue to collect data, constantly discover new nursing problems, reevaluate nursing objects, and develop new plans and measures.

2) Implement nursing measures as planned.

3) Oral shift and written shift report, the execution of nursing procedures within 24 hours is continuous.

4) Writing nursing records, using PIO recording methods, namely Problem, Intervention and Outcome.

evaluate

Evaluation is the activity of comparing the patient's health status with the expected nursing goal in a planned and systematic way. In the implementation of nursing procedures, the focus of evaluation is the patient's health status, and the responsibility for evaluation is borne by the responsible nurse.

The purpose of evaluation: 1) to determine whether the patient has achieved the expected effect or goal; 2) Review the nursing procedures to determine whether the nursing assessment is comprehensive, the nursing diagnosis is correct, and the nursing plan is appropriate.

Content of evaluation: physical appearance and function; Special symptoms and signs; Knowledge aspect; Operational skills; Psychological and emotional aspects. It is used to measure the degree of achievement of the goal: the goal is fully achieved, the goal is partially achieved, and the goal is not achieved.

Evaluation methods: investigation, comparison, observation, statistical analysis;

Evaluation steps: collect data, judge the effect, analyze the reasons, and revise the plan (stop, revise, delete, add).

Forms of evaluation: nursing round, nursing consultation, discharge nursing record discussion, nursing record quality evaluation.