Part Two
- Registration policy and nursing plan
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Politics :
The services department is committed to providing nursing care according to the patient's needs and documenting them in the nursing care plan for each patient.
Purpose :
1. Understand the patient's needs and meet them.
2. Providing high-quality nursing care.
Steps:
The nursing team performs :
1. Make a nursing assessment of the patient upon admission and identify the patient's problems.
2. Write down the patient's nursing problems in the nursing plan, including: (problems / needs - nursing intervention-evaluation-signature).
3. Write the necessary procedures to help solve nursing problems.
4. Re-evaluation to determine the patient's response to nursing interventions.
5. The supervisor of the department follows up the plan and implements its procedures.
In charge :
Department supervisor-responsible nursing.
Models :
Sample nursing care plan.
References :
Comprehensive hospital accreditation guides.
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Policy:
the nursing services department is committed to accurate nursing registration 24 hours a day in a correct, accurate and readable manner
Purpose:
Registration of all patient data.
Teaching the members of the health team to register in the nursing forms in a correct, accurate and readable way.
Steps :
The members of the nursing team :
1. Registration of each activity performed for the patient from the moment of his entry in his form.
2. The team begins by evaluating the patient with the form prepared for this.
3. The main complaint of the patient is identified and the needs are identified.
4. Planning the care that will be provided to the patient.
5. Implement the plan carefully to get the desired results.
6. Evaluate the plan every shift to identify the development of the situation.
7. Repeat any of the steps of the plan in which the patient's condition has not improved.
8. Follow-up vital signs and inform the doctor when there is any change from normal rates.
9. The need to work and file a report on any emergency incident during the work period, such as (patient's fall-patient's escape _ error in giving treatment ).
10. The members of the health team should take care of recording the nursing development, including (the patient's condition-the doctor's recommendations-all medical procedures, analyzes and rumors-surgical interventions-nursing intervention-the patient's assessment has not been updated of signs and symptoms).
In charge :
Nursing staff members
Models :
Nursing notes-nursing assessment-vital signs-nursing care plan-treatment maps
References:
Operational Manual of Nursing Services at the Ministry of Health.
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