Writing error and initialing the entry

Draw inferences and identify problems. (data analysis) = third step; document inferences AKA “hunches” about each cue cluster. Consider nursing diagnosis, collaborative problem, referral. \\ - Question asks about what is done something about cluster ques, what would the phase be?

Step three requires the nurse to document inferences (hunches or assumptions) about each cue cluster

Hypothesized and generate possible nursing diagnoses may be wellness, or health promotion diagnoses - opportunity for enhancement of health state; risk diagnoses - potential noted; or actual diagnoses- currently noted; and syndrome diagnoses. \\ Check for defining characteristics of those diagnoses. (data analysis) = fifth step; check for defining characteristics for the data clusters and hypothesized diagnoses in order to choose the most accurate diagnoses and get rid of the invalid diagnosis. Compare findings with NANDA.\\
Confirm or rule out nursing diagnoses. (data analysis) = sixth step; If cluster data meets with defining characteristics, validate diagnosis with client and other health care providers who are caring for the client. If not, tests to verify to ___. \\
Document conclusions. (data analysis) = seventh step; Document Professional observations and the data that support the diagnoses, collaborative problems, and
referrals \\

Compare and contrast Health Promotion, Risk, Actual and

e.g., impaired skin integrity: reddened area on right buttocks. \\
collaborative diagnoses = are defined as certain “physiological complications that nurses monitor to detect their onset or changes in status”. \\

Identify safe guidelines for documentation of client data.

- Avoid wordiness that creates redundancy and be concise. Use statements.

- Use phrases instead of sentences to record data. Instead of using right and left, use bilateral.

- Record complete information and details for all client symptoms or experiences. “Client reports…”

- Include additional assessment content when applicable. For example, include information about the caregiver or last physician contact.