Assessment - gather data
Diagnosis - problem
Outcome Identification - goals, what we want to happen, expect to happen
Planning - treatmentplan, intervention
Implementation - doing the plan
Evaluation - Was it successful, meet the goals
2. Define Subjective Data
What patient says about himself or herself during history taking
symptoms
3. Define Objective Data
Observed when inspecting, percussing, palpating, and auscultating patient during physical
examination
signs
4. Factors of Diagnosis
-Cluster of data that seem to be associated in some way.
-Validate data, confirm accuracy
-Look for gaps in your information
-Interpret data and identify problems
-Document the diagnosis
5. Factors of Outcome Identification
,-Identify expected outcomes related to pa- tient individualization
-Ensure outcomes have the SMART components
-Specify short-term and long-term goal measurement criteria
-Establish priorities based on meeting patients care goals
-Develop outcomes and set time frames for meeting outcomes
-Identify relevant interventions and utilize interdisciplinary health care team mem- bers for the
patient
-Document plan of care
8. Factors of Evaluation
-Refer to outcomes
-Evaluate patient's condition and compare actual outcomes to expected outcomes
-If reached outcome
does something need to be done
-If NOT reached
identify reasons for not achieving
-Modify plan if needed
, -Document in plan of care
9. Evidence-Based Decision Making factors
-Best evidence from clinical review of research literature
-The providers clinical expertise
-Patient's preference and values
-Physical examination and assessment of patient
10. Focused Database
Problem-centered Used for a limited or short-term problem
Smaller scope and more targeted than the complete database
11. Complete Database
Includes a complete health history and full physical examination
Yielding the first diagnosis
12. Steps in Priority Problem Levels
1. First-level priority
emergent, life threatening, immediate
2. Second- level
next in urgency, requires attention to prevent further deterioration
3. Third-Level
important to patient's health, but can be addressed after urgent problems
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