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PoC documentation provides the ability for clinicians to document patient findings and assessments, as well as plans of care while at the patients bedside or while in the exam room.
Nursing documentation mainly consists of a clients background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the clients data captured at the relevant stages of the nursing process.
Assess the patient. Identify and list nursing diagnoses. Set goals for (and ideally with) the patient. Implement nursing interventions. Evaluate progress and change the care plan as needed.
Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse [1]. Nursing documentation is the principal clinical information source to meet legal and professional requirements [2].
Types of Nursing Care Plans Care plans can be informal or formal: An informal nursing care plan is a strategy of action that exists in the nurses mind. A formal nursing care plan is a written or computerized guide that organizes the clients care information.
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The purpose of a nursing care plan is to document the patients needs and wants, as well as the nursing interventions (or implementations) planned to meet these needs. As part of the patients health record, the care plan is used to establish continuity of care.
Essential Elements of Nursing Documentation Evaluations. Clinical problems. Communication with other healthcare providers. Communication with and education of the patient, family, the individual designated as the patients caregiver and other third parties. Medication records.
ADPIE is an acronym used to remember the five consecutive steps of the nursing process, which include assessment, diagnosis, planning, implementation, and evaluation. Ensuring all five stages of the nursing process are completed is essential in securing systematic, individualized patient care.

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