Documenting patient care.
Use the ANA Scope and Standards of Practice to respond to the following
Question: Select a competency from each of the following and explain how the RN
incorporates the competency in their practice:
Standard 1: Assessment
Standard 2: Diagnosis
Standard 3: Outcomes Identification
Standard 4: Planning
Standard 5: Implementation
Standard 6: Evaluation
Base your paper on your readings and research of this topic using materials for this course
listed below.
Text books, chapters and materials to read for this paper.
1-Treas, L. & Wilkinson, J, (2014). Basic nursing: concepts, skills & reasoning.
Philadelphia; F. A. Davis, Company.
2- Nursing diagnosis text book, Nanda, any…
Required:
Textbooks:
Nursing Diagnosis
� Use your chosen Nursing Diagnosis Guidebook to review the nursing diagnoses specific
to the content covered in this module.
Basic nursing: concepts, skills & reasoning
� Chapter 2: Critical thinking and the nursing process
� Chapter 3: Assessment
� Chapter 4: Diagnosis
� Chapter 5: Planning Outcomes
� Chapter 6: Planning Interventions
� Chapter 7: Implementation and Evaluation
� Chapter 18: Documenting and Reporting
� Chapter 44: Nursing Informatics
Web Based and Other Professional Resources:
� Pre-licensure KSAs (2014)
DOCUMENTING PATIENT CARE 2
� Hospital: 2016 National Patient Safety Goals (2015)
DOCUMENTING PATIENT CARE
In recent times, it has become fundamental for RN in practice to incorporate their
competencies and skills while performing their roles in the health sector. The nursing process
requires the RN to ensure the effectiveness of every plan of care by adhering to standards and
regulations of practice which are intertwined with skills thus leading to positive outcomes (Treas
& Wilkinson, 2014). Systematic and comprehensive skills are one of the competencies applied
by RN during the assessment process. The competency enhances efficiency in acquiring accurate
and relevant data which is also guided by the extensive knowledge to prioritize the available and
historical data. The ability to make informed decisions and been accountable for all decisions is a
competency incorporated by RN during diagnosis processes. The RN adopts these skills to
ensure efficacy in clinical decisions, the diagnostic investigation which is dependent on critical
thinking. The incorporation of such skills results to appropriate course of action after the
diagnosis. Outcome identification requires the RN to incorporate analytical and proactive
competencies which guide them in contributing to healthcare processes positively. Such
competency is essential in practices of outcome identification. Thus the RN focuses on acquiring
the desired results and managing the situations effectively (Treas & Wilkinson, 2014).
Effective communication is a competency incorporated in the process of planning. The
RN that applies the competency can collaborate with other healthcare professionals, and patients
to achieve the set objectives. The RN would also be able to use technical skills during
communication with patients which enhances efficiency while planning for care and
management of their issues. It is also essential to incorporate leadership competencies in the
DOCUMENTING PATIENT CARE 3
implementation of the plans in the nursing process. The incorporation of such skills enhances
efficiency in taking charge of the situation and ensuring they are followed to the letter (Treas &
Wilkinson, 2014). The competency also influences the RN to adopt evidence-based practices
since they are held responsible for all the measures or strategies they use and implement. The
ability to interpret clinical outcomes while ensuring professional integrity is a competence used
by RN during evaluation. The competency is important as it helps the RN to monitor the
outcomes of the plans and find appropriate measures to address gaps identified during the
nursing process of care. In a nutshell, critical thinking needs to be incorporated in all these
processes while applying competencies to result in positive impacts.
DOCUMENTING PATIENT CARE 4
Reference
Treas, L. & Wilkinson, J, (2014). Basic nursing: concepts, skills & reasoning. Philadelphia; F. A.
Davis, Company.