Role of Communication in the Nursing Process III: Evaluation and Documentation

A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:

• • Improved patient's condition
• • Stabilization of the patient's condition
• • Worsening of the patient's health.

Nursing evaluation entails gathering data, comparing it to desired outcomes, analyzing patient responses to nursing activities, and identifying factors contributing to the care plan's success or failure.

Nurses and healthcare team members are legally required to document patient care. Documentation should be objective, factual, and professional and use proper medical terminology, grammar, and spelling. All documentation must include the date, time, and signature of the person documenting. Abbreviations should be avoided. Any documentation in a health record is considered a legal document and must be completed in an accurate and timely manner. A real-time, patient-centered electronic health record (EHR) makes information available to authorized users promptly and securely.

Nursing documentation records the nursing care planned for and given to specific patients by licensed nurses or other caregivers acting under a licensed nurse's guidance. Nursing documentation is the primary clinical information source to satisfy legal and professional standards. Whether it is carried out manually or electronically, it is essential to safe, moral, and efficient nursing practice.

The Purpose of Documentation

Documentation is used for many purposes. It is used to ensure continuity of care across healthcare team members and shifts, monitor standards of care for quality assurance activities, and provide information for reimbursement purposes by insurance companies, Medicare, and Medicaid. Documentation may also be used for research purposes or, in some instances, legal concerns in a court of law.

Disclaimer: This text is adapted from Nursing Fundamentals, Open RN, Section 2.5.Documentation,