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Evidence-based guidelines

Paul H Barrett, Grant Okawa, Jill Bowman

    The Permanente Journal
    |June 11, 2011
    PubMed

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    Guidelines for Writing Outcome01:11

    Guidelines for Writing Outcome

    When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
    Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care evaluation by...
    Guidelines for Nursing Documentation I01:30

    Guidelines for Nursing Documentation I

    Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
    Factual:  
    The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
    Guidelines for Nursing Documentation II01:26

    Guidelines for Nursing Documentation II

    Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
    Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
    Pre-Procedural Guidelines for Assessing Blood Pressure01:10

    Pre-Procedural Guidelines for Assessing Blood Pressure

    Accurate blood pressure assessment is crucial for diagnosing and managing various health conditions. To ensure the reliability of these measurements, healthcare professionals must adhere to standardized pre-procedural guidelines. These guidelines enhance patient safety and improve the overall quality of healthcare. The following steps are essential for obtaining accurate and consistent blood pressure readings, from using the appropriate tools to ensuring effective communication with the patient.
    Standards of Care II01:19

    Standards of Care II

    Nurses bear specific legal responsibilities under several federal statutes, including:
    Methods of Documentation V: CBE01:23

    Methods of Documentation V: CBE

    Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
    In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...