ASSESSMENT "Collect dais ‘view ofthe enial record Interview Health Misty Physical examination Functional assessment ‘Consutaton Review ofthe iterature EVALUATION + Refer to estabiehod outcomes: + Evaluate the indvidua's condition and ‘compare actual outcomes with ‘expected outcomes + Summarize the resuts ofthe ‘evaluation + Identity reasons forthe person's ‘allure indicated to achveve expected ‘outcomes stated inthe plan of care + Take corrective action to modly the plan of care as necessary + Document the evaluation ofthe person's achievement af outcomes [Bnd the modifications, any inte Blan of care IMPLEMENTATION + Review the planed interventions + Schedule and coordinate the person's total healthcare + Collaborate with other team members + Supervise implementation ofthe ‘cate plan by delegating ‘appropriate responsbiies + Counsel the person and significant others + Involve the person inthe heath care + Refer individuals who require “THE INDIVIDUAL ‘continuing care + Document the care provided DIAGNoSis + Interpret ata Identity clusters of eves Make inferences, + Volidate inferences + Compare custers of cues wih definition an Setinng characteristics + Hdontity rated factors + Document the diagnosis ‘OUTCOME IDENTIFICATION + Identify expected outcomes ‘indhedusize fo te person ‘Realistic and measurable ‘nelude a time frame PLANNING + Establish pioiies {Develop outcomes 1 Set ime frames for outcomes ‘identity itervenvons. * Document plan of care