EVALUATION AND DOCUMENTATION

SUBMITTED TO: MRS. MA. ELLEN CORTES - TESTON, RN FUNDA / GROUP #5

— INTRODUCTION —
2.2
1.0 EVALUATION
● To evaluate is to judge or to appraise.
● Evaluating is the fifth phase of the nursing
process. In this context, evaluating is a
planned, ongoing, purposeful activity in which
clients and healthcare professionals determine
○ (a) the client’s progress toward
achievement of goals or outcomes
and
○ (b)the effectiveness of the nursing
care plan.
● Evaluation is an important aspect of the
nursing process because conclusions drawn
from the evaluation determine whether the
nursing interventions should be terminated,
continued, or changed.
● Evaluation is the sixth standard of the ANA
2.3
Standards of Practice and states that “the
registered nurse evaluates progress towards
attainment of outcomes” (ANA, 2015, p. 66).
● Evaluation is continuous. Evaluation done
while or immediately after implementing a
nursing order enables the nurse to make
on-the-spot modifications in an intervention.
● Through evaluating, nurses demonstrate
responsibility and accountability for their
actions, indicate interest in the results of the
nursing activities, and demonstrate a desire
not to perpetuate ineffective actions and
instead to adopt more effective ones.
PROCESS EVALUATION
★ focuses on how the care was given. It answers
questions such as these:
○ Is the care relevant to the client’s
needs?
○ Is the care appropriate, complete,
and timely?
● Process standards focus on the manner in
which the nurse uses the nursing process.
○ Some examples of process criteria
are “Checks client’s identification
band before giving medication” and
“Performs and records chest
assessment, including auscultation,
once per shift.”
OUTCOME EVALUATION
★ focuses on demonstrable changes in the
client’s health status as a result of nursing
care.
★ Outcome criteria are written in terms of client
responses or health status, just as they are for
evaluation within the nursing process.
○ For example, “How many clients
undergoing hip repairs develop
pneumonia?” or “How many clients
who have a colostomy experience an
infection that delays discharge?”

2.0 TYPES OF EVALUATION

Quality assurance requires evaluation of three

components of care: structure, process, and outcome.
Each type of evaluation requires different criteria and
methods, and each has a different focus.

2.1 STRUCTURE EVALUATION

★ focuses on the setting in which care is given. It

answers this question: What effect does the
setting have on the quality of care?
★ Structural standards describe desirable
environmental and organizational
characteristics that influence care, such as
equipment and staffing.
 — INTRODUCTION —
1.0 DOCUMENTATION
Documentation is anything written or printed
that is relied on as a record of proof for authorized
Two records are required:
persons. Documentation and reporting in nursing are
needed for continuity of care; it is also a legal
requirement showing the nursing care performed or not
performed by a nurse.
1.1 LONG-TERM CARE DOCUMENTATION
● Long-term facilities usually provide two types
of care: skilled or intermediate. Clients needing
skilled care require more extensive nursing
care and specialized nursing skills
● Requirements for documentation in long-term
care settings are based on professional
standards, federal and state regulations, and
the policies of the healthcare agency.
PRACTICE GUIDELINES
Complete the assessment and screening forms (MDS)
and plan of care within the time period specified by
regulatory bodies.
Keep a record of any visits and of phone calls from
family, friends, and others regarding the client.
Write nursing summaries and progress notes that
comply with the frequency and standards required by
regulatory bodies.
Review and revise the plan of care every 3 months or
whenever the client’s health status changes.
Document and report any change in the client’s
condition to the primary care provider and the client’s
family within 24 hours.
Document all measures implemented in response to a
change in the client’s condition
. Make sure that progress notes address the client’s
progress in relation to the goals or outcomes defined in
the plan of care.
1.2 HOME CARE DOCUMENTATION
● In 1985, the Health Care Financing
Administration, a branch of the U.S.
GROUP 5 | FUNDA | EVALUATION AND DOCUMENTATION |MRS. MA. ELLEN CORTES - TESTON, RN
Department of Health and Human Services,
mandated that home healthcare agencies
standardize their documentation methods to
meet requirements for Medicare and Medicaid
and other third-party disbursements.
○ (a) a home health certification and
plan of treatment form; and
○ (b) a medical update and client
information form.
● The nurse assigned to the home care client
usually completes the forms, which must be
signed by both the nurse and the attending
primary care provider.
PRACTICE GUIDELINES
Complete a comprehensive nursing assessment and
develop a plan of care to meet Medicare and other
third-party payer requirements. Some agencies use the
certification and plan of treatment form as the client’s
official plan of care.
Write a progress note at each client visit, noting any
changes in the client’s condition, nursing interventions
performed (including education and instructional
brochures and materials provided to the client and
home caregiver), client responses to nursing care, and
vital signs as indicated.
Provide a monthly progress nursing summary to the
attending primary care provider and to the reimburser
to confirm the need to continue services..
Keep a copy of the care plan in the client’s home and
update it as the client’s condition changes
Report changes in the plan of care to the primary care
provider and document that these were reported.
Medicare and Medicaid will reimburse only for the
skilled services provided that are reported to the
primary care provider.
Encourage the client or home caregiver to record data
when appropriate.
Write a discharge summary for the primary care
provider to approve the discharge and to notify the
reimbursers that services have been discontinued.
Include all services provided, the client’s health status
at discharge, outcomes achieved, and
recommendations for further care.
PAGE 2
 — REFERENCE —
2.0 PRACTICE GUIDELINES IN
DOCUMENTATION Berman, A. T, Snyder, S. & Frandsen, G. (2021,
January 5). Kozier & Erb’s Fundamentals of
Nursing, Global Edition. Pearson Higher Ed.
DO DON’T http://books.google.ie/books?id=WxcnEAAA
QBAJ&dq=Kozier+and+Erb%27s+Fundame
Chart a change in a client’s Leave a blank space for ntals+of+Nursing,+EBook,+Global+Edition&
condition and show that a colleague to chart hl=&cd=1&source=gbs_api
follow-up later.
actions were taken.

Read the nurse’s notes prior Chart in advance of the

to care to determine if there event (e.g., procedure,
has medication).
been a change in the client’s
condition.

Be timely. A late entry is Use vague terms (e.g.,

better than no entry; “appears to be
however, the comfortable,” “had a
longer the period of time good night”).
between actual care and
charting, the
greater the suspicion.

Use objective, specific, and Chart for someone else.

factual descriptions. • Record “patient” or
“client” because it is
their chart.

Correct charting errors. Alter a record even if

requested by a superior
or a primary care
provider.

Chart all teaching. Record assumptions or

words reflecting bias
(e.g., “complainer,”
“disagreeable”).

Record the client’s actual

words by putting quotes
around the
words.

Chart the client’s response

to interventions.

Review your notes—are

they clear and do they
reflect what you
want to say?

GROUP 5 | FUNDA | EVALUATION AND DOCUMENTATION |MRS. MA. ELLEN CORTES - TESTON, RN PAGE 3