Advancing the #WordsMatter Movement: Changing Chief Complaint to Chief Concern

Focusing involves centering a conversation on a message's critical elements or concepts. Focusing is valuable if the talk is vague or patients begin to repeat themselves. Sometimes, when patients are asked about their symptoms, they may go off-topic and try to tell their entire life story. Respectfully, the nurse should bring the conversation back into focus.
This therapeutic technique can also be used when a patient brings up pertinent information during a health-related conversation. The...

Patient-centered care involves delivering care beyond inpatient hospitalization. Reflective practice can enhance a patient-centered approach. Reflective practice is a process of reasoning that considers all aspects of the present situation, including practicalities, learning from personal practice, and consideration of patient needs. Patients appreciate care decisions made while considering their input. Involving the patient in their care provides the patient with a sense of contribution rather...

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:

Nurses bear specific legal responsibilities under several federal statutes, including:

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...

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.