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Nursing Process

Coding

Nursing Process
The six steps of the nursing process focus on patient care provided by
nurses and allied health personnel in clinical practice settings. They are
described below:

1. Assessment
Care Components provide the standardized framework classes for
documenting, linking, and tracking patient care. A Care Component
starts the care process by assessing the patient problems for an
episode of care. It is also used to link, map, and code the six steps of
the nursing process via encounters or visits, as well as provide the
analysis and measures for evidencebased practice. For more information,
please visit the Care Components
section of this website or the
Components Table.

2. Diagnosis
A Nursing Diagnosis is used to identify
the specific atomic-level diagnostic
conditions based on the patient
problems, signs and symptoms, and/or
assessed care components that require
nursing care. They are selected from the
CCC of Nursing Diagnoses. For more
information, please visit the Nursing
Diagnoses section of this website or the
Diagnoses Table.

3. Outcome Identification
Each Nursing Diagnosis requires an Expected Outcome or the
anticipated goal of the identified care interventions and actions needed
to treat the patients conditions. Three qualifiers are written in the
present tense to predict care outcomes:

To Improve patient's condition


To Stabilize patient's condition
To Support Deterioration or Death of patient's condition

4. Planning
The Nursing Interventions are atomic-level concepts that represent
services identified to develop a plan of care for the patient. They are
needed to treat each diagnostic condition and/or patient problem
assessed as requiring care. They are selected from the CCC of Nursing
Interventions.For more information, please visit the Interventions
section of this website or the Interventions Table.

5. Implementation
Each Nursing Intervention requires an Action Type as the major focus
for the care. It depicts the specific nursing intervention action. It can
provide the measures needed to determine care outcomes, resources,
and/or costs. Four qualifiers are used to provide the Action Types:
1.
2.
3.
4.

Monitor/Assess/Observe = Action to monitor the patient condition.


Perform/Direct Care/Provide = Action to perform direct patient care.
Teach/Educate/Instruct = Action to educate patient or caregiver.
Manage/Refer/Contact = Action to manage patient care.

6. Evaluation
Each Nursing Diagnosis requires an Actual Outcome depicting the
outcome of care resulting from the interventions and action types used
to treat the patient. The same three qualifiers used to predict the
Expected Outcomes or care goals are also used to evaluate whether
the care outcomes and/or goals were met or not met. Three qualifiers
are written in past tense to depict actual outcomes:
1. Patients condition Improved
2. Patients condition Stabilized
3. Patients condition Deteriorated, Died, or Discharged.

Copyright Virginia K Saba 1994, 2004, 2013-14 | Admin Panel