Documenting patient care Assignment Paper

Documenting patient care
   Documenting patient care

Documenting patient care

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Topic :Documenting patient care.

Use the ANA Scope and Standards of Practice to respond to the following:

Question: Select a competency from each of the following and explain how the RN incorporates the competency in their practice:

  • Standard 1: Assessment
  • Standard 2: Diagnosis
  • Standard 3: Outcomes Identification
  • Standard 4: Planning
  • Standard 5: Implementation
  • Standard 6: Evaluation

Base your paper on your readings and research of this topic using materials for this course listed below.

Text books, chapters and materials to read for this paper.

1-Treas, L. & Wilkinson, J, (2014). Basic nursing: concepts, skills & reasoning. Philadelphia; F. A. Davis, Company.
2- Nursing diagnosis text book, Nanda, any…

Nursing Diagnosis
• Use your chosen Nursing Diagnosis Guidebook to review the nursing diagnoses specific to the content covered in this module.

Basic nursing: concepts, skills & reasoning**
• Chapter 2: Critical thinking and the nursing process
• Chapter 3: Assessment
• Chapter 4: Diagnosis
• Chapter 5: Planning Outcomes
• Chapter 6: Planning Interventions
• Chapter 7: Implementation and Evaluation
• Chapter 18: Documenting and Reporting
• Chapter 44: Nursing Informatics

Web Based and Other Professional Resources:
• Pre-licensure KSAs (2014)**
• Hospital: 2016 National Patient Safety Goals (2015)


In recent times, it has become fundamental for RN in practice to incorporate their competencies and skills while performing their roles in the health sector.  The nursing process requires the RN to ensure the effectiveness of every plan of care by adhering to standards and regulations of practice which are intertwined with skills thus leading to positive outcomes (Treas & Wilkinson, 2014). Systematic and comprehensive skills are one of the competencies applied by RN during the assessment process. The competency enhances efficiency in acquiring accurate and relevant data which is also guided by the extensive knowledge to prioritize the available and historical data. The ability to make informed decisions and been accountable for all decisions is a competency incorporated by RN during diagnosis processes. The RN adopts these skills to ensure efficacy in clinical decisions, the diagnostic investigation which is dependent on critical thinking. The incorporation of such skills results to appropriate course of action after the diagnosis. Outcome identification requires the RN to incorporate analytical and proactive competencies which guide them in contributing to healthcare processes positively. Such competency is essential in practices of outcome identification. Thus the RN focuses on acquiring the desired results and managing the situations effectively (Treas & Wilkinson, 2014).

Effective communication is a competency incorporated in the process of planning. The RN that applies the competency can collaborate with other healthcare professionals, and patients to achieve the set objectives. The RN would also be able to use technical skills during communication with patients which enhances efficiency while planning for care and management of their issues. It is also essential to incorporate leadership competencies in the implementation of the plans in the nursing process. The incorporation of such skills enhances efficiency in taking charge of the situation and ensuring they are followed to the letter (Treas & Wilkinson, 2014). The competency also influences the RN to adopt evidence-based practices since they are held responsible for all the measures or strategies they use and implement. The ability to interpret clinical outcomes while ensuring professional integrity is a competence used by RN during evaluation. The competency is important as it helps the RN to monitor the outcomes of the plans and find appropriate measures to address gaps identified during the nursing process of care. In a nutshell, critical thinking needs to be incorporated in all these processes while applying competencies to result in positive impacts.


Treas, L. & Wilkinson, J, (2014). Basic nursing: concepts, skills & reasoning. Philadelphia; F. A. Davis, Company.

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