General information Teaching 2334

Charting language
Skilled nurse developed patient plan of care with patient/caregiver involvement to be countersigned by physician. SN to perform complete physical assessment each visit with emphasis on disease process. SN to assess other co-morbidities including list diseases and other conditions that present themselves during this episode of care. SN to recognize and intervene to minimize complications; notify physician immediately of any potential problems that impede completion of patient recovery and desired goals.

Reviewed September 2018

Reviewed for general reference only. Adapt to your patient, agency policy, and scope of practice.