Nursing Leadership in Home and Community Care: An Introduction

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities

Nursing involves independent, cooperative, person-centered care for people of all ages, families, groups, and communities. Nurses assist the sick or the well person in all settings. Nursing includes promoting health, preventing illness, and caring for ill, disabled, and dying people. Health promotion encourages people to take responsibility for their health. It focuses on the healthy behavior of individuals, families, and the community and the factors that impact their health. Examples of...

The planning phase of the nursing process helps nurses set priorities, outline patient-centered goals and expected outcomes, and tailor nursing interventions to align with the aligned care plan. Through the planning phase, the nurse applies critical thinking skills to align and develop interventions according to the patient's needs. It provides continuity of care allowing patients to receive the maximum benefit from treatment. It serves as a pilot plan for allocating individual staff to a...

Implementation is the execution of the nursing care plan developed during the planning phase.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.

A nursing care plan can present in two forms: informal and formal. Informal is a care plan for the individual use of the nurse and goals they wish to accomplish during their shift. Informal care plans are not included in the patient chart. A formal nursing care plan is a written or computerized guide that organizes patient care. It is further subdivided into two: standardized and individualized care plans. Standardized care plans are pre-populated care plans for specific patient populations,...

An interdisciplinary team includes many healthcare professionals working together and utilizing their skills, knowledge, and expertise to provide holistic and quality patient care.
Physicians
The physician's primary responsibility is to diagnose illness and direct the medical or surgical treatment of the condition. The authority to admit patients to a healthcare agency or institution and practice care within that setting is granted to physicians by the healthcare agency or institution...