PNC 121 --1.pdf

Introduction to Practical Nursing and the Nursing Profession (Week 1) Categories of Nurses: ○ Registered Nurse (RN), ○ Nurse Practitioner (NP), ○ Registered Psychiatric Nurse ○ Registered Practical Nurse (RPN)/Licensed Practical Nurse (LPN). Occupation vs...

Introduction to Practical Nursing and the Nursing Profession (Week 1) Categories of Nurses: ○ Registered Nurse (RN), ○ Nurse Practitioner (NP), ○ Registered Psychiatric Nurse ○ Registered Practical Nurse (RPN)/Licensed Practical Nurse (LPN). Occupation vs. Profession: ○ Nursing is a profession because it requires specialized knowledge, ethical guidelines, and public service. Practice Settings: ○ Institutional Sector: Hospitals, long-term care facilities. ○ Community Sector: Public health, home care. Issues and Trends in Practical Nursing: ○ Educational preparation and entry-level competencies. ○ Continuing education requirements for RPNs. ○ Workplace trends and issues like staffing shortages. Key Test Information from Professional Practice Standards and Nursing Concepts CNO Practice Standards: ○ Set expectations for nurses to ensure public protection. ○ Inform nurses of their responsibilities and help the public understand what to expect. CNO Code of Conduct (6 Principles): ○ Respect for clients’ dignity. ○ Provide inclusive, culturally safe care. ○ Ensure safe and competent care. ○ Collaborate respectfully with healthcare teams. ○ Act with integrity in clients' best interest. ○ Maintain public confidence in nursing. Fitness to Practice: Nurses must maintain physical, emotional, and mental health to provide safe care. Duty to Provide Care: Nurses are ethically obligated to provide care unless personal risk is too high. Nursing Practice Concepts: ○ Competency: Safe, organized care for one stable client. ○ Connectedness: Therapeutic nurse-client relationships. ○ Health & Healing: Use of knowledge to assess and plan care. ○ Critical Thinking: Evidence-based decisions. ○ Professionalism: Following standards and workplace policies. Week 2: Communication Overview Definition of Communication: Communication involves exchanging ideas, facts, or feelings to reach a shared understanding. Nurses use communication to influence others and must interact effectively with patients, families, and teams. Therapeutic Communication: This promotes a patient's physical and emotional well-being. It involves techniques like listening, clarifying, and showing empathy to build rapport and trust. Therapeutic communication helps build trust and rapport between the nurse and the patient, making it easier to provide patient-centered care. Types of Communication: Interprofessional Communication: This occurs between members of different healthcare teams, ensuring effective collaboration across various disciplines. Intraprofessional Communication: This type of communication happens within members of the same healthcare team. It is essential for maintaining consistency and cooperation within the team. Intrapersonal Communication: Often referred to as “self-talk” or “inner thought,” this form of communication occurs within an individual. It helps develop self-awareness, positive self-concept, and can improve health and self-esteem. Interpersonal Communication: This is the face-to-face interaction between a nurse and a patient. It is the most common form of communication in healthcare settings, requiring the nurse to consider the patient’s values, beliefs, experiences, and opinions throughout the communication process. Verbal Communication: This involves the use of spoken or written words. Non-verbal Communication: This includes the transmission of messages without words, using body language, gestures, facial expressions, and other sensory cues. Electronic Communication: Refers to the use of technology for documentation and sharing information in healthcare. Factors Influencing Communication: Things like physical/psychological disabilities, developmental concerns, cognitive changes, language barriers, cultural differences, personal space, touch, and the patient’s emotional state can affect communication with patients. Therapeutic Communication Techniques: Some techniques that help nurses build rapport and encourage patients to engage in meaningful conversations about their care Active listening Sharing observations, empathy, hope, and humor Clarifying and paraphrasing Asking relevant questions Using silence and self-disclosure Summarizing discussions Using touch when appropriate Barriers to Communication: Barriers such as asking personal questions, giving opinions, changing the subject, false reassurance, or providing automatic responses can negatively affect communication. Other barriers include showing sympathy instead of empathy, requesting explanations, offering approval or disapproval, defensive behavior, passive or aggressive responses, and arguing. Nurse-Patient Helping Relationship: This relationship is structured into four goal-directed phases: Pre-interaction: Before meeting the patient, the nurse gathers information and prepares for the interaction. Orientation: The nurse and patient meet, establish trust, and define roles. Working: This is the phase where the nurse and patient work together to achieve health goals. Termination: Marks the end of the relationship once the patient’s goals have been met. Creating a Therapeutic Environment: A nurse’s ability to communicate effectively plays a pivotal role in providing a therapeutic environment. A supportive environment enhances the patient’s sense of control, facilitates emotional comfort, and aids in their recovery. Client-Centred Care: Nurses ensure client-centered care by focusing on the individual’s unique needs and life experiences. This approach moves beyond just addressing the illness or disease and considers the patient's whole life story, including the role of their family in their health journey. Maintaining Boundaries: Nurses must always be mindful of maintaining professional boundaries in their relationships with patients. While it’s important to build rapport and trust, there should be clear limits to prevent boundary violations. Accepting gifts from patients is generally discouraged, though there may be certain situations where small tokens of appreciation are appropriate. Nurses should be vigilant in identifying any boundary drifts and addressing them before they become violations. Protecting Clients from Abuse: Nurses have a duty to protect clients from any form of abuse. They should be alert to signs of abuse, whether it is emotional, physical, psychological, or financial, and take appropriate actions to safeguard the patient’s well-being. Week 3: Communication in Clinical Practice Data Collection: In the nursing process, the first step is assessment. Nurses collect relevant information about the patient's health, including data from nursing health histories and physical assessments. Sources of Data: Primary Sources: Directly from the patient, including subjective data from their personal experiences, symptoms, and perceptions.  Secondary Sources: From family members, other healthcare professionals, or medical records. Tertiary Sources: Literature, clinical guidelines, or research articles that provide additional context or information relevant to the patient’s condition. Phases of an Interview: Orientation Phase: The nurse introduces themselves, explains the purpose of the interview, and establishes trust with the patient. Working Phase: This is where the nurse gathers information, observes both verbal and non-verbal communication, and asks questions to get a full picture of the patient’s health. Termination Phase: The nurse concludes the interview, ensuring that the patient understands the next steps and any follow-up actions. Questioning Techniques: Open-ended Questions: These invite patients to share more detailed responses, helping nurses explore broader issues and identify the patient’s priorities. Closed-ended Questions: These require yes or no answers and are typically used when specific information is needed or when time is limited. Observation During an Interview: Nurses should use their senses to observe the patient's appearance, body language, and patterns of interaction. It’s important to take a holistic approach, considering not only the physical but also the emotional, psychosocial, and spiritual aspects of the patient’s health Special Needs Considerations: Adapt communication strategies for patients with disabilities, language barriers, or cognitive challenges. When conducting interviews with patients who have special needs, such as language barriers, cognitive impairments, or physical disabilities, nurses must adapt their communication strategies to ensure that the patient understands and can respond appropriately. This may involve using simpler language, visual aids, or interpreters. Nursing Admission Interview: The goal is to gather a health history and assess risks, including the reason for seeking care and medical background. The purpose of the nursing admission interview is to gather a comprehensive health history, identify health problems, and assess risk factors. Impact of Culture: Be aware of cultural factors that can influence communication, healthcare beliefs, and patient expectations. Culture can significantly influence how patients communicate, understand, and respond to healthcare. Cultural considerations may also affect the patient’s health beliefs, decision-making processes, and expectations for care. Professional Communication Among Health Care Workers Miscommunication is one of the primary causes of errors in healthcare settings. Problems, especially between nurses and physicians, can lead to dissatisfaction and negatively impact teamwork. Disruptive Behavior Disruptive behaviors include actions like bullying, lateral violence, and incivility. Such behaviors can harm team dynamics and patient care. It's essential for healthcare workers to recognize these behaviors and know how to address them appropriately. Assertive Communication Assertive communication involves clearly and confidently expressing your needs while respecting others. For nurses, this is crucial in advocating for patients and collaborating effectively with the healthcare team. Non-assertive communication, such as staying silent when something should be said, can lead to negative patient outcomes and ineffective teamwork. Professional Communication Styles Nurses tend to use descriptive communication, providing detailed and thorough information. Physicians, on the other hand, typically communicate more briefly, focusing on problem-solving. The SBAR model (Situation, Background, Assessment, Recommendation) is used to structure communication, ensuring clarity: Situation: What is happening now? Background: What is the relevant patient history? Assessment: What is the current assessment of the patient? Recommendation: What action should be taken? SBAR Report The SBAR model is widely used in clinical settings to ensure that information is passed along clearly and effectively, especially in high-pressure situations like nurse-to-physician communication or during patient hand-offs. It helps ensure that important information is conveyed efficiently and accurately. Nursing Rounds and Reports During nursing rounds, communication should be concise and focused on the patient’s admission reason, progress, and barriers to discharge. Reports can be given in various formats such as in-person, bedside (considering confidentiality), recorded, or written. Transfer reports, in particular, are brief and cover the patient’s history, diagnosis, progress, and goals for discharge. Giving and Receiving Feedback Effective communication includes the ability to give and receive constructive feedback. This is essential for personal development and improving clinical practice Week 4 Clinical Research Development of Research in Nursing Nursing research began with Florence Nightingale. The first nursing research journal in Canada, Nursing Papers, was published in 1969. Research is essential for developing the knowledge necessary for nursing practice. Research Nursing research can either test existing theories or generate new ones based on findings. It is crucial for nurses to consider nursing within the broader healthcare context. Scientific knowledge in nursing is constantly evolving through research. Clinical Research Expectations Clinical research must be regularly reviewed and updated to remain relevant and useful in practice. This reflects the dynamic nature of nursing research and its application to patient care. Research Literacy Being research literate means being able to locate, understand, and critically evaluate literature for its application in practice. Critical evaluation includes assessing the scientific merit, clinical relevance, and trustworthiness of research findings. Nurses must determine whether evidence is applicable and reliable for use in clinical practice. Types of Research Quantitative Research: Involves statistical analysis and can include: ○ Experimental Research: Examines how one variable affects another. ○ Descriptive Designs: Looks for relationships between variables. ○ Exploratory Descriptive Designs: Provides detailed descriptions of populations or variables. Qualitative Research: Focuses on non-numerical data and includes: ○ Ethnography: Studies people in their natural environment. ○ Phenomenology: Describes experiences from the perspective of those who live them. ○ Grounded Theory: Aims to understand the meaning of social interactions and actions. ○ Participatory Action Research: Collaborates with participants to address social issues.  ○ Interpretive Descriptive Research: Focuses on generating knowledge relevant to health disciplines. ○ Narrative Inquiry: Records lived experiences of individuals or groups. Evidence-Based Practice (EBP) EBP involves using current, high-quality research evidence to inform clinical decisions. Nurses practicing EBP understand what to do, how to do it, and the evidence supporting their actions. Evidence-Informed Practice (EIP) EIP considers various types of evidence, including research, patient assessment, clinical expertise, and patient preferences, to guide healthcare decisions. Steps of the Evidence-Informed Practice Process 1. Formulate a clinical question using the PICO format. 2. Gather relevant and best evidence. 3. Critically appraise the evidence. 4. Integrate evidence with clinical expertise and patient preferences to make decisions. 5. Evaluate the outcome. 6. Share the results. RNAO Best Practice Guidelines The Registered Nurses Association of Ontario provides Best Practice Guidelines (BPG) to ensure nurses use evidence-based interventions. Critical Thinking Critical thinking is both a process and a skill set essential for nurses to navigate complex healthcare environments. It requires knowledge, reflective reasoning, and the ability to analyze and make informed decisions. Importance of Critical Thinking in Nursing Nurses need to think critically to manage fast-paced, ever-changing healthcare settings. Critical thinking allows nurses to recognize issues, analyze information, evaluate it, and draw meaningful conclusions. Critical Thinking Model for Nursing Judgment  Involves three levels: ○ Basic: Simple, rule-based thinking. ○ Complex: More independent analysis. ○ Commitment: Nurses make decisions based on experience and responsibility. Five components: specific knowledge base, experience, critical thinking competencies, attitudes, and standards. General Critical Thinking Competencies Scientific Method: Involves identifying problems, gathering data, forming hypotheses, testing, and evaluating results. Problem-Solving Process: Clarify the problem, gather information, evaluate solutions, and monitor outcomes. Decision Making: Assess options, weigh them against criteria, and choose the best solution. Specific Critical Thinking Competencies Diagnostic Reasoning & Clinical Inference: The process of analyzing patient information (behaviors, symptoms) to determine health status and make conclusions. Clinical Reasoning: A cognitive process of gathering and interpreting information to decide on patient care actions. Clinical Decision Making: Involves selecting appropriate interventions, distinguishing professional nurses from technical personnel, and applying both reflective and critical thinking. Clinical Judgment Involves the systematic use of the nursing process (assessing, diagnosing, planning, implementing, evaluating) to make complex decisions that combine intuition, critical thinking, and knowledge. Reflective Practice and Critical Thinking Reflective practice is essential for nurses to analyze their actions, learn from experiences, and improve decision-making and critical thinking skills. Recipients of Care - People who need health care Standards and Scope of Practice Regulatory Authority for LPNs  Regulatory Authorities: These are government-appointed bodies responsible for overseeing the practice of LPNs (Licensed Practical Nurses) within their respective jurisdictions. Their role is to ensure that LPNs operate under consistent standards of safety and professionalism. Responsibilities: The regulatory authorities have the legislative responsibility to: ○ Set standards: They define what is expected from LPNs in terms of education, skills, and ethics. ○ Monitor adherence: They ensure that LPNs follow these standards through licensing, continuing education, and periodic review. ○ Enforce standards: If LPNs deviate from established guidelines, regulatory bodies have the power to impose disciplinary actions, such as license suspension or revocation. Scope of Practice for Nurses Scope of Practice: This refers to the specific tasks and responsibilities that a nurse is legally allowed to perform, which vary based on the category of nurse. Each category of regulated nurse—whether LPNs, Registered Nurses (RNs), or Registered Psychiatric Nurses (RPNs)—has a unique scope of practice. ○ Educational Background: The training received during nursing education determines the range of duties an LPN or RN can perform. ○ Performance Requirements: These include the skills and knowledge a nurse must demonstrate, which align with their educational level. ○ Legal Authority: Different categories of nurses are authorized by law to perform certain tasks. For example, an RN may have the legal authority to initiate specific treatments that an LPN is not authorized to perform. Roles in Supporting Scope of Practice Employer: The employer is responsible for providing clear job descriptions and ensuring that policies reflect the legal and ethical boundaries of an LPN’s role. They must ensure LPNs have the resources and support needed to fulfill their duties. Practical Nurse: LPNs must practice within the scope defined by their regulatory body and employer policies. They need to recognize their limitations and seek guidance when faced with tasks outside their training. Supporting RN: In collaborative environments, RNs often work alongside LPNs. RNs may provide oversight, helping LPNs with complex tasks and ensuring compliance with standards of care. Challenges Affecting Scope of Practice Role Conflict: This occurs when the responsibilities of LPNs and RNs overlap or when there is uncertainty about who should perform a specific task. This can lead to inefficiency or conflict within healthcare teams.  Inappropriate Utilization: This happens when LPNs are asked to perform tasks outside their legal or educational scope, which can compromise patient safety and put the LPN at risk of legal consequences. Unclear Policies: When job descriptions are vague, LPNs might not fully understand their responsibilities, which can lead to misunderstandings or role misuse. Career Advancement Interprofessional Collaboration: LPNs can collaborate with other healthcare professionals (e.g., RNs, physicians, therapists) to broaden their knowledge and improve their clinical competencies. Intraprofessional Collaboration: LPNs working closely with other LPNs or professionals within their field to share skills and expand knowledge. Educational Opportunities: Through continued education, LPNs can take courses or certification programs that expand their scope of practice (e.g., in specialty fields like geriatrics or pediatrics). Supervision and Delegation Supervision Supervision refers to the guidance provided by more experienced nurses (often RNs) to less experienced healthcare workers (such as LPNs or nursing students). The goal is to ensure that care is safe and meets the required standards. Supervision refers to the ongoing process in nursing where a more experienced professional (usually an RN or a nurse manager) provides guidance and oversight to less experienced nurses or healthcare workers. Goal: The supervisory relationship helps the less experienced nurse (e.g., a newly qualified LPN) to develop competency while ensuring patient safety and effective care. Delegation Delegation occurs when a nurse transfers authority to perform a specific task to another healthcare provider (such as an LPN). The nurse who delegates the task retains responsibility for the outcome, and the task must fall within the scope of practice of the individual to whom it is delegated. Delegation occurs when one healthcare provider (often an RN) transfers the authority to perform a task to another person (often an LPN). This process ensures that the task is performed within the legal and professional boundaries of the LPN’s scope of practice. Controlled Acts: In nursing, controlled acts (tasks that could cause harm if performed incorrectly) are often delegated under certain conditions. For example, an RN may delegate a procedure to an LPN, such as medication administration, if the LPN is properly trained and supervised. Legislation, Regulatory Bodies, and Professional Associations Role of Regulatory Bodies Regulatory bodies oversee and protect the professional title of LPNs (and other categories of nurses). This ensures that only licensed and registered individuals can use the title, promoting public trust and accountability. Key Function: They are responsible for enforcing standards of practice, conducting licensing exams, and ensuring that all LPNs adhere to ethical and professional guidelines. Controlled or Authorized Acts Controlled Acts are procedures or interventions that carry a risk of harm if performed incorrectly (e.g., administering medication, performing injections, or inserting catheters). Only qualified healthcare providers can perform these acts, and in some cases, they can be delegated under supervision. Controlled or authorized acts (also called restricted or reserved acts) are procedures that are potentially harmful if performed by unqualified individuals. Examples include: ○ Administering certain medications. ○ Performing invasive procedures. Only qualified nurses and professionals with specific training are allowed to perform these acts, and sometimes only under direct supervision or delegation. Self-Regulation Self-regulation is a legislative privilege given to the nursing profession. It allows nurses to regulate themselves through their professional bodies, ensuring they maintain competence and ethical standards. Responsibility: Self-regulated professions ensure that their members adhere to laws, continually develop skills, and remain fit to practice. Professional Associations Professional associations provide a collective platform for nurses to advocate for issues relevant to their profession. They: ○ Engage with government and policy-makers to ensure that the needs and concerns of practical nurses are addressed. ○ Offer networking opportunities and continuing education programs to help nurses develop professionally. ○ Act as a voice for nurses, advocating on behalf of issues like patient safety, working conditions, and career advancement. Week 5 What is Documentation?  Definition: Documentation refers to the process of recording nursing information about care in health records. It reflects the care provided and ensures proper communication between health care providers. Documentation is essential for providing a legal record of patient care, ensuring continuity between healthcare providers, and preventing errors. It is also crucial for maintaining accurate records that can be referenced for legal purposes and audits. Key Elements of documentation include: ○ Factual: Documentation must only include objective data (e.g., vital signs, lab results). ○ Accurate: Entries must be clear and free of errors. ○ Complete: Documentation must cover all relevant aspects of patient care, including medications, interventions, and outcomes. ○ Timely: Nurses should record their notes immediately after patient care is provided to avoid missing important information or introducing errors. Purpose of Nursing Documentation Main Purposes: ○ Reflects the client’s perspective. ○ Communicates the plan of care to all healthcare providers. ○ Integral to interprofessional communication. ○ Demonstrates a nurse’s commitment to providing safe, effective, and ethical care. ○ Ensures compliance with professional standards and regulations. Medical Record (Client Record or Chart) A medical record is a legal document that provides evidence of a client’s care. It can be written or electronic and includes critical information such as care plans, progress notes, and medical history. Purpose: ○ Facilitates interdisciplinary communication and care planning. ○ Provides legal evidence of care provided. ○ Assists in funding, resource management, auditing, and research. Electronic Documentation Advantages: Improved efficiency, easy access, and better coordination. Disadvantages: Potential for security breaches if not managed properly. Security for Computerized Records How to Prevent Breaches:  ○ Keep systems secure by using strong passwords. ○ Ensure only authorized personnel access patient records. ○ Log off electronic records after use. Personal Health Information Protection Act (PHIPA 2004) PHIPA ensures that clients' health information is kept confidential and secure. It also gives clients the right to access their health records and request corrections if needed. Confidentiality Nurses are required to protect patient confidentiality. Only those directly involved in a patient’s care have legitimate access to the patient's records. Critical Thinking in Nursing: Critical thinking is a systematic process that involves analyzing, evaluating, and synthesizing information to make informed decisions. In nursing, critical thinking is essential for assessing patient conditions, developing care plans, and solving complex healthcare problems. Clinical Judgment: Clinical judgment is the ability to use the nursing process (assessment, diagnosis, planning, implementation, and evaluation) to make decisions about patient care. It combines critical thinking, intuition, and evidence-based practice. Reflective Practice: Reflective practice is the process of self-evaluation and continuous learning. By reflecting on their actions, nurses can identify areas for improvement, enhance their clinical skills, and provide better patient care. Content of Patient Records Key Components: ○ Patient identification, demographic data. ○ Informed consent. ○ Admission history, nursing problems, diagnosis, and care plan. ○ Medical history and diagnosis. ○ Progress notes, discharge summary, and patient/family education records. Common Nursing Record Keeping Forms Forms include:  ○ Admission nursing history form. ○ Flow sheets and graphic records. ○ Standardized care plans. ○ Medication Administration Record (MAR). Guidelines for Quality Documentation Documentation should be: ○ Factual: Objective and based on observations. ○ Accurate: Exact and free from errors. ○ Complete: All necessary information is included. ○ Current: Up-to-date. ○ Organized: Logical and easy to follow. ○ Compliant: Meets regulatory standards. Methods of Documentation 1. Narrative: A story-like format; time-consuming and can be repetitive. This is a detailed, chronological account of patient care. While it offers a thorough record, it can be time-consuming and may include unnecessary details. 2. Problem-Oriented Medical Record (POMR): Structured around a database, problem list, care plan, and progress notes. ○ Uses formats like SOAP, SOAPIE, PIE, or DAR. 3. SOAP & SOAPIE: ○ S: Subjective (patient's statements). ○ O: Objective (observations). ○ A: Assessment. ○ P: Plan - The interventions or treatments planned for the patient. ○ I: Intervention. ○ E: Evaluation. 4. PIE: This focuses on identifying patient problems, implementing nursing interventions, and evaluating outcomes. ○ P: Problem. ○ I: Intervention. ○ E: Evaluation. 5. DAR Note: A focus note format where the nurse records specific patient data, the actions taken in response to that data, and the patient’s response to the care provided. ○ D: Data. ○ A: Action. ○ R: Response. 6. Source Records: Information in source records is divided by discipline (e.g., nursing, physical therapy, medicine), so each healthcare provider records their own notes separately. It can be difficult to gather all information about a specific problem in one place because the data is spread out across different sections.  7. Charting by Exception (CBE): Assumes all standards are met unless otherwise documented. CBE is a documentation method where only deviations from the norm or expected outcomes are charted. This assumes that all standards are met unless otherwise documented. Within Defined Limits (WDL): Indicates that the patient's condition is within the expected or normal range. Within Normal Limits (WNL): Denotes that no abnormalities are present in the patient’s assessment. Within defined limits (WDL) or within normal limits (WNL) define normal assessments. Case Management Model Focuses on providing quality, cost-effective care within a defined period using critical pathways, which are interprofessional care plans. This model focuses on delivering high-quality, cost-effective care within a defined period. It uses critical pathways, which are structured care plans developed by an interprofessional team to manage specific conditions. Critical Pathways Care plans identifying patient problems, key interventions, and expected outcomes within a set timeframe. Critical pathways are detailed, interprofessional care plans that outline the patient’s problems, key interventions, and expected outcomes. They are designed to ensure that care is standardized and that the patient achieves expected outcomes within a certain time. Critical pathways help healthcare teams follow evidence-based steps for managing conditions, preventing unnecessary delays or duplication of services Guidelines for Home Health Care Documentation Documentation should enable effective collaboration among healthcare team members, ensuring patients and families are involved and informed. Documentation in home health care must ensure that all healthcare team members, including patients and families, are informed and involved in the care plan. Collaboration among caregivers and healthcare providers is crucial to deliver safe, effective care in a home environment. This includes clear communication of the patient’s progress, medication schedules, and any changes in their condition. Documentation in Long-Term Care Settings  In long-term care (LTC) facilities, documentation is often completed using flow sheets for daily activities and progress notes for significant changes in condition, incidents, or weekly assessments. Documentation Using the Nursing Process The nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation) is a structured approach to patient care, and documentation must reflect each of these steps 1. Assessment Data: Collected during initial patient assessments and recorded in flow sheets and progress notes. 2. Nursing Diagnosis: Documented in the care plan and critical pathways, identifying the patient's health problems and needs. 3. Planning: The care plan outlines the goals for patient care and is often supported by tools like the Kardex, a quick reference summary of the patient’s status and care plan. 4. Implementation: This refers to the actions nurses take based on the care plan. These actions, such as administering medication or assisting with mobility, are recorded in progress notes and flow sheets. Recorded in progress notes and flow sheets. 5. Evaluation: Nurses must document the patient’s response to interventions, noting whether goals were met or if adjustments to the care plan are needed. Telephone and Verbal Orders Telephone Orders (TO): These are orders given by a healthcare provider over the phone, often in urgent situations. Nurses must confirm the order by repeating it back to the provider to ensure accuracy. Verbal Orders (VO): These are face-to-face orders given in person. Like telephone orders, nurses must confirm and accurately document verbal orders. Nurses must confirm orders by spelling out unfamiliar terms, reading back orders, and documenting them correctly. Written Orders These are orders that are either hand-written or electronically entered into a patient’s chart by a healthcare provider. Orders are written directly by the healthcare provider and transcribed if necessary. Nurses should clarify any unclear orders. CNO Documentation Standards Communication: Documentation serves as the primary tool for communication between healthcare team members. It ensures that all care providers are on the same page regarding the patient’s condition, treatment, and progress. Ensuring clear, accurate, and timely documentation.  Accountability: Nurses are accountable for ensuring that their documentation is accurate, complete, and timely. Inaccuracies in documentation can lead to miscommunication, errors in care, or even legal issues. Taking responsibility for the accuracy of records. Security: Safeguarding patient information is essential. Nurses must adhere to strict guidelines for protecting patient records, especially when using electronic systems, to prevent unauthorized access or breaches of confidentiality. This includes logging out of systems after use and ensuring that records are only accessed by authorized personnel.