Documentation of Outcomes and Revision of Plan - Using the Nursing Process

DOCUMENTATION OF OUTCOMES AND REVISION OF PLAN

Outcomes are documented concisely and objectively. Documen-tation should relate outcomes to the nursing diagnoses and col-laborative problems, describe the patient’s responses to the interventions, indicate whether the outcomes were met, and in-clude any additional pertinent data.

The plan of care is subject to change as the patient’s needs change, as the priorities of the needs shift, as needs are resolved, and as additional information about the patient’s state of health is collected. As the nursing interventions are implemented, the pa-tient’s responses are evaluated and documented and the plan of care is revised accordingly. A well-developed, continuously up-dated plan of care is the greatest assurance that the patient’s nurs-ing diagnoses and collaborative problems will be addressed and his or her basic needs will be met.