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Using and documenting nursing diagnosis in an ambulatory setting

G Bru

    Journal of the Association of Pediatric Oncology Nurses
    |January 1, 1989
    PubMed

    Related Concept Videos

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    A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
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    Documentation of Nursing Diagnosis01:10

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    The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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    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:
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