Performs initial assessment appropriate to the patient’s clinical presentation/diagnosis, care setting, age development level, and cultural and religious orientation in a timely manner.
Performs and documents completely and accurately including, but not limited to, physical (i.e., assessment for pain, skin breakdown, risk for falls), psychological (i.e., cognitive and communicative skills or development), social status and other patient needs.
Identifies and prioritizes the need for further assessment based on the patient’s clinical presentation/diagnosis, care setting, desire for care, and response to any previous care.
Initiates discharge planning for each patient upon admission as appropriate.
Is individualized for each patient based on assessment of needs that include input from the patient, family and other multi-disciplinary health care team members.
Identifies specific nursing diagnosis is relevant to assessment findings.
Identifies and performs interventions for each nursing diagnosis, specific to identified patient needs.
