Questions: The nurse should document the assessment during which phase of the nursing process?

The nurse should document the assessment during which phase of the nursing process?
Transcript text: The nurse should document the assessment during which phase of the nursing process?
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Solution

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The answer is: Assessment

Explanation for each option:

  1. Assessment: This is the correct answer. During the assessment phase of the nursing process, the nurse collects and documents comprehensive data pertinent to the patient's health or situation. This includes gathering information through patient interviews, physical examinations, and reviewing medical records.

  2. Diagnosis: This phase involves analyzing the assessment data to determine the issues or problems the patient is experiencing. The nurse identifies and labels the patient's health problems, but this is not the phase where the initial data collection and documentation occur.

  3. Planning: In the planning phase, the nurse sets measurable and achievable short- and long-term goals for the patient based on the diagnosis. The nurse also plans interventions to address the diagnosed problems. Documentation here involves the care plan, not the initial assessment data.

  4. Implementation: During the implementation phase, the nurse carries out the planned interventions. Documentation in this phase includes recording the actions taken and the patient's responses to those actions, but it does not involve the initial assessment.

  5. Evaluation: In the evaluation phase, the nurse assesses the patient's progress toward the goals set in the planning phase. The nurse documents the outcomes and any necessary modifications to the care plan. However, this phase does not involve the initial assessment documentation.

In summary, the nurse should document the assessment during the Assessment phase of the nursing process.

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