Care plan

ning
standards

Standard of Care I: Assessment

THE NURSE CARING FOR ACUTE AND
CRITICALLY ILL PATIENTS COLLECTS
RELEVANT PATIENT HEALTH DATA.
Measurement Criteria
1. Data collection involves the patient, family, and other
healthcare providers as appropriate to develop a holistic
picture of the patient's needs.
2. The priority of data collection activities is driven by
the patient's immediate condition and/or anticipated
needs.
3. Pertinent data are collected using appropriate
assessment techniques and instruments.
4. Data are documented in a retrievable form.
5. Data collection process is systematic and ongoing.

Standard of Care II: Diagnosis

THE NURSE CARING FOR ACUTE AND
CRITICALLY ILL PATIENTS ANALYZES THE
ASSESSMENT DATA IN DETERMINING
DIAGNOSES.
Measurement Criteria
1. Diagnoses are derived from the assessment
data.
2. Diagnoses are validated throughout the
nursing interactions with the team consisting of
the patient, family, and other healthcare
providers, when possible and appropriate.
3. Diagnoses are prioritized and documented in a
manner that facilitates determining expected
outcomes and developing a plan of care.
4. Diagnoses are documented in a retrievable
form.

Standard of Care III: Outcome

Identification
THE NURSE CARING FOR ACUTE AND
CRITICALLY ILL PATIENTS IDENTIFIES
INDIVIDUALIZED, EXPECTED OUTCOMES
FOR THE PATIENT.
Measurement Criteria
1. Outcomes are derived from actual or potential diagnoses.
2. Outcomes are mutually formulated with the patient, family,
and other health care providers, when possible and appropriate.
3. Outcomes are individualized in that they are culturally
appropriate and realistic in relation to the patient's age and
present and potential capabilities.
4. Outcomes are attainable in relation to resources available to
the patient.
5. Outcomes are measurable and should include a time estimate
for attainment, if possible.
6. Outcomes provide direction for continuity of care so that the
nurse's competencies are matched with the patient's needs.
7. Outcomes are documented in a retrievable form.

Standard of Care IV: Planning

THE NURSE CARING FOR ACUTE AND
CRITICALLY ILL PATIENTS DEVELOPS A PLAN
OF CARE THAT PRESCRIBES
INTERVENTIONS TO ATTAIN EXPECTED
OUTCOMES.
Measurement Criteria
1. The plan is individualized to reflect the patient's
characteristics and needs.
2. The plan is developed collaboratively with the
team, consisting of the patient, family, and healthcare
providers, in a way that promotes each member's
contribution toward achieving expected outcomes.
3. The plan reflects current acute and critical care
nursing practice.
4. The plan provides for continuity of care.
5. Priorities for care are established.
6. The plan is documented to promote continuity of
care.

Standard of Care V: Implementation

THE NURSE CARING FOR ACUTE AND
CRITICALLY ILL PATIENTS IMPLEMENTS
INTERVENTIONS IDENTIFIED IN THE PLAN
OF CARE.
Measurement Criteria
1. Interventions are delivered in a manner that
minimizes complications and life-threatening
situations.
2. The patient and family participate in
implementing the plan of care based upon
their ability to participate in and make
decisions regarding care.
3. Interventions are documented in a
retrievable manner.

Standard of Care VI: Evaluation

THE NURSE CARING FOR ACUTE AND
CRITICALLY ILL PATIENTS EVALUATES THE
PATIENT'S PROGRESS TOWARD ATTAINING
EXPECTED OUTCOMES.

Measurement Criteria
1. Evaluation is systematic, ongoing, and criterion-based.
2. The team consisting of patient, family, and healthcare
providers is involved in the evaluation process as
appropriate.
3. Evaluation occurs within an appropriate time frame after
interventions are initiated.
4. Ongoing assessment data are used to revise the
diagnoses, outcomes, and plan of care as needed.
5. Revisions in diagnoses, outcomes, and plan of care are
documented.
6. The effectiveness of interventions is evaluated in relation
to outcomes.
7. The patient's responses to interventions are documented.