26Ŧ 8eporLlng

of lncluded
evaluaLlon
Lhereof
0 Accordlng Lo venzonţ nagLalon
(2010) nurslng ManagemenL
1owards CuallLy Careţ
documenLaLlon should lnclude
paLlenL's responsesţ whlch ls
evaluaLlonŦ 1hey also lndlcaLed a
guldellne for good reporLlng and
documenLaLlon LhaL lncludes belng
compleLe whlch should descrlbe
nurslng care and Lhe cllenL's
response Lo LhaL careŦ ln addlLlonţ lL
also sLaLed Lhe guldellne for belng
currenL LhaL ln documenLaLlon lL
should noLe Lhe changes ln cllenL's
condlLlon whlch may refer Lo
evaluaLlon of hls condlLlonŦ
lurLhermoreţ Lhe AssoclaLlon of
nurslng Servlce AdmlnlsLraLors of
Lhe Þhlllpplnesţ lncŦ (AnSAÞ)
CommlLLee on nurslng ÞracLlce
made a manual of Lhe SLandards of
nurslng Servlces and sLandard lv
refers Lo Lhe evaluaLlon of care
whlch lndlcaLed measurable
elemenLs whlch sLaLes LhaL
sysLemaLlc and conLlnuous
evaluaLlon of paLlenL's progress and
effecLlveness of care should be
reflecLed ln Lhe lndlvlduallzed
paLlenL record and LhaL paLlenL's
responses Lo lnLervenLlons are
documenLedŦ Moreoverţ Lhe flrsL
key area of responslblllLles for
llllplno nurses as lndlcaLed by Lhe
8oard of nurslng ls Safe and CuallLy
nurslng Care whlch under lL ls Core
CompeLency whereln Lhe nurslng
process ls uLlllzed as a framework
for nurslng and has anoLher subŴ
core compeLency 7Ŧ4 whlch
evaluaLes progress Loward expecLed
ouLcomesŦ Slnce Lhe hosplLal has
Lhe proLocol of followlng Lhe SCAÞ
(Sub[ecLlve daLaţ Cb[ecLlve daLaţ
AssessmenL/nurslng dlagnoslsţ
Þlannlng/lnLervenLlons) meLhod of
charLlng evaluaLlon of Lhe
lnLervenLlons ls noL lncludedŦ ln Lhe
0 Accordlng Lo venzonţ nagLalon
(2010) nurslng ManagemenL
1owards CuallLy Careţ
documenLaLlon should lnclude
paLlenL's responsesţ whlch ls
evaluaLlonŦ 1hey also lndlcaLed a
guldellne for good reporLlng and
documenLaLlon LhaL lncludes belng
compleLe whlch should descrlbe
nurslng care and Lhe cllenL's
response Lo LhaL careŦ ln addlLlonţ lL
also sLaLed Lhe guldellne for belng
currenL LhaL ln documenLaLlon lL
should noLe Lhe changes ln cllenL's
condlLlon whlch may refer Lo
evaluaLlon of hls condlLlonŦ
lurLhermoreţ Lhe AssoclaLlon of
nurslng Servlce AdmlnlsLraLors of
Lhe Þhlllpplnesţ lncŦ (AnSAÞ)
CommlLLee on nurslng ÞracLlce
made a manual of Lhe SLandards of
nurslng Servlces and sLandard lv
refers Lo Lhe evaluaLlon of care
whlch lndlcaLed measurable
elemenLs whlch sLaLes LhaL
sysLemaLlc and conLlnuous
evaluaLlon of paLlenL's progress and
effecLlveness of care should be
reflecLed ln Lhe lndlvlduallzed
paLlenL record and LhaL paLlenL's
responses Lo lnLervenLlons are
documenLedŦ Moreoverţ Lhe flrsL
key area of responslblllLles for
llllplno nurses as lndlcaLed by Lhe
8oard of nurslng ls Safe and CuallLy
nurslng Care whlch under lL ls Core
CompeLency whereln Lhe nurslng
process ls uLlllzed as a framework
for nurslng and has anoLher subŴ
core compeLency 7Ŧ4 whlch
evaluaLes progress Loward expecLed
ouLcomesŦ ln addlLlonţ Lhe 8oard of
nurslng 8oard 8esoluLlon noŦ 220
Serles of 2004ţ ÞromulgaLlon of Lhe
Code of LLhlcs for 8eglsLered
nursesţ ArLlcle lll SecLlon 6ţ (3)
sLaLes LhaL accuraLe documenLaLlon
of acLlons and ouLcomes of
8oard of nurslng 8oard 8esoluLlon
noŦ 220 Serles of 2004ţ
ÞromulgaLlon of Lhe Code of LLhlcs
for 8eglsLered nursesţ ArLlcle lll
SecLlon 6ţ (3) sLaLes LhaL accuraLe
documenLaLlon of acLlons and
ouLcomes of dellvered care are Lhe
hallmark of nurslng accounLablllLyŦ
dellvered care are Lhe hallmark of
nurslng accounLablllLyŦ Slnce Lhe
hosplLal has Lhe proLocol of
followlng Lhe SCAÞ (Sub[ecLlve daLaţ
Cb[ecLlve daLaţ AssessmenL/nurslng
dlagnoslsţ Þlannlng/lnLervenLlons)
meLhod of charLlng evaluaLlon of
Lhe lnLervenLlons ls noL lncludedŦ
27Ŧ ÞaLlenL or
famlly alerLed
as Lo whaL Lo
reporL Lo
physlclan
1 ln venzonţ nagLalon (2010) nurslng
ManagemenL 1owards CuallLy Careţ
lL sLaLed Lhere LhaL nurslng
lnLervenLlons should be deLalled
enough so Lhere wlll be no
mlsundersLandlng or
mlslnLerpreLaLlon buL upon Lhe
revlew of Lhe paLlenL's charL Lhere
were Lwo (2) SCAÞ charLlng done by
Lhe nurses whlch encouraged
paLlenLs and slgnlflcanL oLhers Lo
verballze needs and concerns buL lL
was noL speclfled Lo Lhem whaL
should be reporLed especlally whaL
slgns and sympLoms should Lhey be
alerLed Lo reporL Lo Lhe docLorŦ Cn
Lhe oLher handţ 10 ouL of 24 or 41Ŵ
42Ʒ of Lhe nurses' noLes had
reporLs or sub[ecLlve daLa glven by
Lhe paLlenL or slgnlflcanL oLhers as
Lo whaL Lhe paLlenL ls currenLly
experlenclng especlally slgns and
sympLoms ln relaLlon Lo paLlenL's
condlLlonŦ Poweverţ Lhese
documenLaLlon dld noL speclflcally
lndlcaLe LhaL Lhe paLlenL or famlly
were lnsLrucLed Lo reporL lL dlrecLly
Lo Lhe physlclanŦ Cn Lhe oLher handţ
accordlng agaln Lo Lhe same
auLhors aboveţ Lhls provldes for
famlly and paLlenL parLlclpaLlon as
much as posslble whlch ls one of
Lhe clLed crlLerla for a nurslng care
planŦ
1 ln venzonţ nagLalon (2010) nurslng
ManagemenL 1owards CuallLy Careţ
lL sLaLed Lhere LhaL nurslng
lnLervenLlons should be deLalled
enough so Lhere wlll be no
mlsundersLandlng or
mlslnLerpreLaLlonŦ upon Lhe revlew
of Lhe paLlenL's charL Lhere were 7
ouL of 28 or 23Ʒ of Lhe SCAÞ
charLlngs encouraged paLlenLs and
slgnlflcanL oLhers Lo verballze needs
and concerns buL lL was noL
speclfled Lo Lhem whaL should be
reporLed especlally whaL slgns and
sympLoms should Lhey be alerLed Lo
reporL Lo Lhe docLorŦ Cn Lhe oLher
handţ 7 ouL of 28 or 23Ʒ also
lndlcaLed speclflc slgns and
sympLoms Lo be reporLed such as
chesL palnţ dypnea and dlzzlnessŦ
lurLhermoreţ 12 ouL of 28 or 42Ŵ
43Ʒ of Lhe nurses' noLes had
reporLs or sub[ecLlve daLa glven by
Lhe paLlenL or slgnlflcanL oLhers as
Lo whaL Lhe paLlenL ls currenLly
experlenclng especlally slgns and
sympLoms ln relaLlon Lo paLlenL's
condlLlonŦ Poweverţ Lhese
documenLaLlon dld noL speclflcally
lndlcaLe LhaL Lhe paLlenL or famlly
were lnsLrucLed Lo reporL lL dlrecLly
Lo Lhe physlclanŦ Cn Lhe oLher handţ
accordlng agaln Lo Lhe same auLhors
aboveţ Lhls provldes for famlly and
paLlenL parLlclpaLlon as much as
posslble whlch ls one of Lhe clLed
crlLerla for a nurslng care planŦ
28Ŧ 8ecord
permlLLed
conLlnulLy of
4 venzonţ nagLalon (2010) nurslng
ManagemenL 1owards CuallLy Care
lndlcaLed Lhe purposes of a wrlLLen
4 venzonţ nagLalon (2010) nurslng
ManagemenL 1owards CuallLy Care
lndlcaLed Lhe purposes of a wrlLLen
lnLramural and
exLramural
care
nurslng care plan whlch ls for
conLlnulLy of careŦ A wrlLLen nurslng
care plan organlzes lnformaLlon
whlch ls dlscussed durlng
endorsemenLs or changeŴofŴshlfL
reporLs and lL ls lmporLanL Lo have
currenL and perLlnenL lnformaLlon
from shlfL Lo shlfL and from day Lo
day for conLlnulLy of careŦ ln
addlLlonţ Lhey also dlscussed
communlcaLlon as a purpose of
documenLaLlon where Lhe charL
serves Lo faclllLaLe conLlnulLy of
care Lhrough keeplng Lrack of
paLlenL's progress and condlLlon
and measures Laken Lo malnLaln
conLlnulLy of care and also a
reference polnL for furLher
assessmenLŦ upon revlew of Lhe
charLţ every shlfL or 100Ʒ have
documenLed ln every shlfL for Lhe
whole course of conflnemenL of Lhe
paLlenL LhaL allowed for conLlnulLy
of careŦ lL lndlcaLed LhaL paLlenL was
endorsed and referred and Lhe
slmple presence of daLa or
lnformaLlon ln Lhe charL permlLLed
noL only Lhe nexL nurse on duLy buL
as well as Lhe docLors and oLher
healLh care professlonals Lo be
updaLed and lnformed on cllenL's
condlLlonŦ 1hls subfuncLlon ls
furLher supporLed by Core
CompeLency 3ť Lnsures conLlnulLy
of care under Lhe flrsL key areas of
responslblllLles of llllplno nurses
whlch ls Safe and CuallLy nurslng
CareŦ
nurslng care plan whlch ls for
conLlnulLy of careŦ A wrlLLen nurslng
care plan organlzes lnformaLlon
whlch ls dlscussed durlng
endorsemenLs or changeŴofŴshlfL
reporLs and lL ls lmporLanL Lo have
currenL and perLlnenL lnformaLlon
from shlfL Lo shlfL and from day Lo
day for conLlnulLy of careŦ ln
addlLlonţ Lhey also dlscussed
communlcaLlon as a purpose of
documenLaLlon where Lhe charL
serves Lo faclllLaLe conLlnulLy of care
Lhrough keeplng Lrack of paLlenL's
progress and condlLlon and
measures Laken Lo malnLaln
conLlnulLy of care and also a
reference polnL for furLher
assessmenLŦ upon revlew of Lhe
charLţ every shlfL or 100Ʒ have
documenLed ln every shlfL for Lhe
whole course of conflnemenL of Lhe
paLlenL LhaL allowed for conLlnulLy
of careŦ lL lndlcaLed LhaL paLlenL was
endorsed and referred and Lhe
slmple presence of daLa or
lnformaLlon ln Lhe charL permlLLed
noL only Lhe nexL nurse on duLy buL
as well as Lhe docLors and oLher
healLh care professlonals Lo be
updaLed and lnformed on cllenL's
condlLlonŦ 1hls subfuncLlon ls
furLher supporLed by Core
CompeLency 3ť Lnsures conLlnulLy
of care under Lhe flrsL key areas of
responslblllLles of llllplno nurses
whlch ls Safe and CuallLy nurslng
CareŦ
1C1AL
vlŦ AppllcaLlon and LxecuLlon of nurslng procedures and Lechnlques
29Ŧ
AdmlnlsLraLlon
and/or
supervlslon of
medlcaLlons
Ŧ3 7 ouL of Lhe 24 charLlngs or 29Ŵ30Ʒ
have lndlcaLed LhaL due meds were
glven and LhaL Lhls can also be
reflecLed Lo Lhe medlcaLlon sheeL
where every medlcaLlons
prescrlbed were duly glven and
slgnedŦ Poweverţ ln Lhls
subfuncLlonţ Þfaneuf descrlbed lL as
Ŧ3 ln Lhls subfuncLlonţ Þfaneuf
descrlbed lL as wheLher Lhe charL
reflecLs nurse or paLlenL or famlly
awareness of expecLed LherapeuLlc
resulLs and posslble unLoward slde
effecLsŦ 10 ouL of Lhe 28 charLlngs or
33Ŵ36Ʒ have lndlcaLed LhaL due
meds were glven and LhaL Lhls can
wheLher Lhe charL reflecLs nurse or
paLlenL or famlly awareness of
expecLed LherapeuLlc resulLs and
posslble unLoward slde effecLsŦ 8uL
as seen ln Lhe charLţ lL was noL
acLually speclflcally lndlcaLed
wheLher Lhe nurse acLually
explalned abouL Lhe LherapeuLlc
and slde effecLs of Lhe medlcaLlons
glven and LhaL under Lhe lawţ
anyLhlng LhaL ls noL documenLed ln
paLlenL careţ ls noL done or
rendered no maLLer how excellenL lL
lsŦ Alsoţ ln Lhe flrsL key areas of
responslblllLles of llllplno nurses
whlch ls Safe and CuallLy nurslng
Care whlch under lL ls Core
CompeLency 6ť AdmlnlsLers
medlcaLlons and oLher healLh
LherapeuLlcs and here we should
conslder Lhe 10 golden rules ln drug
admlnlsLraLlon and we may
conslder here Lhe rlghL paLlenL
Leachlng or educaLlon abouL Lhe
medlcaLlons LhaL Lhe paLlenL ls
LaklngŦ
also be reflecLed Lo Lhe medlcaLlon
sheeL where every medlcaLlons
prescrlbed were duly glven and
slgnedŦ As seen ln Lhe charLţ lL was
noL acLually speclflcally lndlcaLed
wheLher Lhe nurse acLually
explalned abouL Lhe LherapeuLlc
and slde effecLs of Lhe medlcaLlons
glven and LhaL under Lhe lawţ
anyLhlng LhaL ls noL documenLed ln
paLlenL careţ ls noL done or
rendered no maLLer how excellenL lL
lsŦ AlLhoughţ 2 ouL of Lhe 28
charLlngs or 7Ŵ8Ʒ have noLed LhaL
due medlcaLlons were glvenţ well
LoleraLed wlLh no adverse reacLlonsŦ
Alsoţ ln Lhe flrsL key areas of
responslblllLles of llllplno nurses
whlch ls Safe and CuallLy nurslng
Care whlch under lL ls Core
CompeLency 6ť AdmlnlsLers
medlcaLlons and oLher healLh
LherapeuLlcs and here we should
conslder Lhe 10 golden rules ln drug
admlnlsLraLlon and we may conslder
here Lhe rlghL paLlenL Leachlng or
educaLlon abouL Lhe medlcaLlons
LhaL Lhe paLlenL ls LaklngŦ
30Ŧ Þersonal
care (baLhlngţ
oral hygleneţ
sklnţ nall careţ
shampoo)
Ŧ3 Cnly 2 ouL of 24 or 8Ŵ9Ʒ of Lhe
charLs lndlcaLed LhaL mornlng care
was done whlch may refer Lo
paLlenL's personal care alLhough noL
speclflc or deLalled as Lo whaL were
lncluded ln Lhe mornlng care and
mlghL be mlsundersLood whlch
vlolaLes one of Lhe crlLerla for
nurslng lnLervenLlons should be
compleLe or deLalled enough so
Lhere wlll be no mlsundersLandlng
or mlslnLerpreLaLlon as clLed ln
venzonţ nagLalon (2010) nurslng
ManagemenL 1owards CuallLy CareŦ
lurLhermoreţ we may assume LhaL
oLher nurses dld perform Lhls
subfuncLlon buL as sLaLed earllerţ
under Lhe lawţ anyLhlng LhaL ls noL
documenLed ln paLlenL careţ ls noL
done or rendered no maLLer how
Ŧ3 1he flrsL key areas of responslblllLles
of llllplno nurses whlch ls Safe and
CuallLy nurslng Care lncluded Core
CompeLency 3ť ÞromoLes safeLy and
comforL and prlvacy of cllenLs and
LhaL a parL of Lhls ls personal
hyglene of Lhe paLlenL ln order Lo
promoLe comforLŦ Cne (1) ouL of 28
or 3Ŵ4Ʒ of Lhe charLs lndlcaLed LhaL
mornlng care was done whlch may
refer Lo paLlenL's personal care
alLhough noL speclflc or deLalled as
Lo whaL were lncluded ln Lhe
mornlng care and mlghL be
mlsundersLood whlch vlolaLes one
of Lhe crlLerla for nurslng
lnLervenLlons should be compleLe or
deLalled enough so Lhere wlll be no
mlsundersLandlng or
mlslnLerpreLaLlon as clLed ln
excellenL lL lsŦ 1he flrsL key areas of
responslblllLles of llllplno nurses
whlch ls Safe and CuallLy nurslng
Care lncluded Core CompeLency 3ť
ÞromoLes safeLy and comforL and
prlvacy of cllenLs and LhaL a parL of
Lhls ls personal hyglene of Lhe
paLlenL ln order Lo promoLe
comforLŦ
venzonţ nagLalon (2010) nurslng
ManagemenL 1owards CuallLy CareŦ
lurLhermoreţ we may assume LhaL
oLher nurses dld perform Lhls
subfuncLlon buL as sLaLed earllerţ
under Lhe lawţ anyLhlng LhaL ls noL
documenLed ln paLlenL careţ ls noL
done or rendered no maLLer how
excellenL lL lsŦ

CCnCLuSlCnS
1he charLlngs are parLlally lncompleLe and noL LhaL comprehenslve as compared Lo Lhe
sLandards ln documenLaLlon and LhaL Lhls lmplles LhaL our key areas of responslblllLles and core
compeLencles may have noL been adequaLely performed whlch ls acLually vlLal noL only for us nurses
and for Lhe whole healLh care Leam and as well as for our paLlenLs and Lhelr famllles slnce
documenLaLlon ls noL only a legal documenL buL a way Lo communlcaLe wlLh Lhe healLh care Leam and
provlde conLlnuousţ updaLedţ accuraLeţ deLalled and compleLe record of paLlenL's progress and lL ls also
an lmplemenLed plan of care for our paLlenLs and Lhelr famllles ln order Lo saLlsfy Lhem as our cllenLs
and ln order Lo acLually perform our duLy as a nurseŦ
8LCCMMLnuA1lCnS
uurlng paLlenL's conflnemenLţ nurses used Lhe SCAÞ charLlng whlch has a dlsadvanLage of noL
belng able Lo evaluaLe Lhe paLlenL whlch ls slgnlflcanL ln Lhe documenLaLlonŦ 8uLţ slnce laLely Lhe
hosplLal adapLed Lhe uA8 charLlng Lhen lL would be beLLer or lf Lhey dld noL shlfL Lo uA8ţ lL ls
recommended LhaL Lhey use SCAÞlL8 charLlng whlch noL only lncludes evaluaLlon buL also revlslonŦ
Moreoverţ lL may also be suggesLed LhaL nurses should be relnforced by hlgher auLhorlLles such as Lhe
chlef/head nurse or nurse supervlsor LhaL Lhey lmprove on Lhelr documenLaLlon and follow Lhe
sLandards and crlLerla for documenLaLlon slnce lL ls a legal documenL and for more accuraLe and deLalled
lnformaLlon for beLLer undersLandlng and conLlnulLy of careŦ

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f  n °   ¾ .

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f  °n  .

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