Professional Documents
Culture Documents
3. Health Education
Assess the learning of the patient and family
- Obtain learning information through interview, observation and validation
- Defines relevant information
- Completes assessment records appropriately
- Identifies priority need
Develops health education plan based on assessed and anticipated needs
- Considers the nature of the learner with respect to social, cultural, political,
economic, educational and religious factors.
Develops learning materials for health education
- Involves the patient, family and significant others
- Formulates a comprehensive health education plan with these components:
content, time allotment, teaching-learning resources and evaluation parameters
- Provides for feedback to finalize the plan
Implements the health education plan
- Provides for a conductive learning situation in terms of the place
- Considers client and family’s preparedness
- Utilizes appropriate strategies
- Provides reassuring presence through active listening, touch, facial expression
and gestures
- Monitor client and family’s response to health education
Evaluates the outcome of health education
- Utilizes evaluation parameters
- Documents outcome of care
- Revises health education plan when necessary
4. Legal Responsibility
Adhere to practices in accordance with the nursing law and other relevant legislation including
contracts and informed consents
- Fulfills legal requirements in nursing practice
- Holds current professional license
- Acts in accordance with the terms and contract of employment and other rules and
regulations
- Complies with acquired continuing professional education
- Confirms education given by the doctor for the informed consents
- Secures waver for responsibility for refusal to undergo treatment or procedures
- Checks the completeness of informed consents and other legal forms
Adheres to organizational policies and procedures, local and national
- Articulates the vision and mission of the institution where one belongs
- Acts in accordance with the established norms of conduct of the institution /
organization
Documents care rendered to patients
- Utilizes appropriate patient care records and reports
- Accomplishes accurate documentation of all matters concerning patient care in
accordance with the standards of nursing practice
5. Ethico-Moral Responsibility
Respects the rights of individuals / group
- Renders nursing care consistent with the patient bill of rights (Confidentiality of
information, privacy, ect.)
Accepts responsibility and accountability for own decision and actions
- Meets nursing accountability requirements as embodied in the job description
- Justifies basis for nursing action and judgment
- Projects a positive image of the profession
Adheres to the national and international code of ethics for nurses
- Adheres to the Code of Ethics for nurses and abides by its provision
- Reports unethical and immoral incidents to proper authorities
7. Quality Improvement
Gathers data for quality improvement
- Demonstrate knowledge of method appropriate to the clinical problems identified
- Detects variation in the vital signs of the patient from day to day
- Reports necessary elements at the bedside to improve patient’s stay at the hospital
- Solicits feedback from patient and significant others regarding care rendered
Participate in nursing audits and rounds
- Contributes relevant information about patient condition as well as patients reactions
- Shares with the team regarding current information on the patient’s condition as well as
patients reactions
- Encourages the patient to speak what is relevant to his/her condition
- Documents and records all nursing care and actions
- Performs daily check of patients records/condition
- Completes patients records
- Actively contributes relevant information of patients during rounds through readings
and sharing with others
Identifies and reports variances
- Documents observed variance regarding patient care and preventive measures
- Communicates and discuss with appropriate groups
- Gives an objective and accurate report on what was observed rather than an
interpretation of the event
Recommends improvement of system and processes
8. Research
Gathers data using different methodologies
- Identifies researchable problems regarding patient care and community health
- Identifies appropriate methods of research for a particular patient / community
problem
- Combines qualitative and quantitative nursing design through sample explanation on
the phenomenon observed
- Analyzes data gathered
Recommends actions for implementation
- Based on analysis of data gathered, recommends practical solutions appropriate for the
problem
Disseminates results of research findings
- Communicates results of findings to colleagues / patients / family and to others
- Endeavors to publish research
- Submits research findings to own agencies and other as may be appropriate
Applies research findings in nursing practice
9. Records Management
Maintains accurate and update documentation and updated documentation of patient care
- Completes updated documentation of patient care
Records outcome patient care
- Utilizes a records system (e.g., Kardex or Hospital Information System)
Observes legal imperatives in record keeping
- Observes confidentiality and privacy of patient records
- Maintains an organized system of filing and keeping records in a designated area
- Refrains from releasing records and other information without proper authority
10. Communication
Establishes rapport with patients
- Creates trust and confidence
- Listens attentively to clients queries and requests
- Spends time with the client to facilitate conversation that allows client to express
concerns
Listens attentively to clients queries and requests
- Interprets and validates patients body language and facial expressions
Identifies verbal and non-verbal cues
- Interprets and validates patients body language and facial expression
Utilizes formal and informal channels
- Makes use of available visual aids
Responds to the need of individuals, family, group and community
- Provides reassurance through therapeutic touch, warmth and comforting words of
encouragement
- Readily smiles
Use appropriate information technology to facilitate
- Utilizes telephone, mobile phone, email, internet and informatics
- Identifies significant others so that follow-up care can be obtained
- Provides “Holding” or emergency number for services