Far Eastern University Institute of Nursing Date: January 14, 2012 Statement of the problem and Cues 1.

The need to provide a good clip boards for the vital signs sheet in each of the clients bed in Medical Ward Room 1 and 2. Cues: The vital sign sheet in the patients bed were already rumpled and sometimes torn Due to lack of clipboards, some of the vital sign Analysis Nursing documentation provides an account of the judgment and critical thinking used in the nursing process (i.e., Assessment, diagnosis, planning, intervention and evaluation). Accurate, timely documentation reflects care provided; meets professional, legislative and agency standards; promotes enhanced nursing care; and facilitates Area: Rizal Medical Center Medical Ward Problem Solving Process Alternative Implementation Rationale Evaluation Course of Action a. The group Nursing Effectiveness: The group will provide documentation We were able to planned to clipboards. provide implement plan A must provide b. Ask the an accurate intervention that because it is the medical and will enhance most convenient team to honest accurate and way for the provide clip account of timely vital sign group. boards what and documentation? The group will c. The group when events Yes_ buy a clipboard will provide occurred, as No_ that has a their reasonable price. well as identify unused who provided Efficiency: The group will clipboards. the care. Good We were able to also provide a Vital signs sheet documentation attain my objectives using for the clip board has five the most for organize vital important characteristics. economical signs It should be: cost? documentation. 1) factual; 2) Yes_ accurate; 3) No_ complete; 4) current Appropriateness:

sheet was not in order with their correspondin g dates The VS sheet of old patient were still attach to the new.

communication Between nurses and other healthcare providers. According to Potter & Perry (2001), nursing documentation must be both comprehensive and flexible enough to obtain critical data, maintain quality and continuity of care, track client1 Outcomes, and reflect current standards. (Potter and Perry, 2001)

(timely); and 5) organized (Potter & Perry, 2001, p.504).

Were our chosen alternative courses of action appropriate? Yes_ No_ Acceptability: Was our plan of action acceptable to the medical staff and patients? Yes_ No_ Adequacy: Were our resources adequate? Yes_ No_