Documentation of findings

1. Health Assessment
Final Research topics (Documentations)
Name: Ann Jerymhe Gonzaga Tampus Date Performed: 04/27/2022
Section: BSN 1K Date Submitted: 04/27/2022
Documentation of findings
• Patient & Family Education & Home Health Teaching
➢ Patient education is a key component to disease management, convalescence,
and overall wellness maintenance. Documentation of patient education provides
a means of monitoring the type of patient education performed, the patient
response, and additional educational needs.
➢ Patient education in home health care continues to hold many challenges for the
professional nurse. With the changing climate of the health care delivery system,
an increasing number of clients are returning to their home "quicker but sicker."
The demand on the nurse to provide more in-depth patient education in the
client's home will increase. The nurse must be prepared to make a thorough
assessment of the client's learning needs, develop and implement an effective
teaching plan, evaluate learning, and revise the plan as necessary, as well as
document the teaching. All of this must be achieved to ensure continuity of
quality patient care and reimbursement by third-party payers.
• Diagnostic Tests (routine laboratory exams)
➢ Documents provide essential guidelines for the laboratory in the form of a quality
manual, SOPs and reference material. They are required part of the laboratory
quality standards. They reflect the laboratory's organization and quality
management. Laboratories maintain documents and records to find information
when it is needed. Verbal instructions often go unheard, or are misunderstood,
quickly forgotten, or difficult to follow.
➢ Routine laboratory tests are blood tests that assess the health status of a
patient. Tests include counts of different types of white blood cells (these help
the body fight infection), and detection of markers (proteins) that indicate organ
damage, and general inflammation.

2. • Appropriate Nursing Diagnosis
➢ A nursing diagnosis is a clinical judgment concerning human response to
health conditions/life processes, or a vulnerability for that response, by an
individual, family, group, or community. A nursing diagnosis provides the basis
for the selection of nursing interventions to achieve outcomes for which
the nurse has accountability. Nursing diagnoses are developed based on data
obtained during the nursing assessment and enable the nurse to develop the
care plan.