Phenix City, AL30+ days ago
Electronically documents on admission assessment, nursing care plan, flow sheets, medicationadministration record and nurses notes all pertinent information, in a manner that is concise, thorough,legible and accurately reflects patient condition, care provided, response to care and conforms toJHMH policy and procedure on charting. PLANNING: Includes the development of a written plan of care that utilizes the data collected in the assessment process, incorporates the medical plan of care, demonstrates knowledge of resources available, sets priorities and establishes realistic outcomes and discharge planning.