In addition, information about a patient, once registered, is inaccessible or, if available, often in a non-standard format (p. E.g., doctor’s words), resulting in numerous errors in omission, misinterpretation and layoffs. Most care planning methods are also considered of little value and face the same poor design, poor accessibility and non-standardization problems. The lack of usefulness of medical registration in daily practice raises the moral question of whether the costs of keeping the file in its current form (about 15 percent of a nurse’s time) are justified.
Werley and Zorn73 first described a minimum set of elements required in the minimum data sets for nurses, and noted that the content should be developed to reflect the specific elements of diagnosis, intervention and outcome of nurses. It is currently the responsibility of the American Association of Nurses’ Nursing Practices Information Infrastructure Committee to establish recognition criteria and formally recognize the terminologies that meet the established criteria. Most articles on interdisciplinary care planning focus on case management or clinical pathways. These arise from specialties and areas that traditionally have closer ties between different professionals to control a patient’s condition. Nurses cited time constraints as the biggest obstacle to interdisciplinary collaboration.
Nurses are responsible for maintaining respectful and collaborative professional relationships and demonstrating effective conflict resolution skills. However, if you cannot solve the problem and decide to refuse to implement any aspect of the patient care plan, you are responsible for effectively communicating your decision to minimize the patient’s risks. This means that specific concerns and steps directly related to patient care are documented in the patient register. Full documentation of nursing care provided and all aspects of the nursing process are required, including evaluation, planning, intervention and evaluation.
When you learn the steps to make a diagnosis, you think like a professional nurse. So every time you get the chance to write nursing assignments, you don’t frown. And if you nursing research topics have mastered the art of writing nursing care plans, whether you study or practice in clinical environments, you can work in community care and mental health centers.
By setting long-term goals, you can make them more achievable by dividing them into smaller goals or goals. In your nursing plan, it is important to set realistic goals to help your patients succeed. If they feel the goal is achievable, you can increase their morale and encourage them to continue working on their health.