The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [46]
5 If an error is made this should be scored out with a single line and the correction written alongside with date, time and initials. Correction fluid should not be used at any time.
6 All assessments and entries made by student nurses must be countersigned by a Registered Nurse.
7 Healthcare assistants:
can write on fluid balance and food intake charts
who have demonstrated achievement of the learning outcomes for observing and monitoring the patient’s condition as defined in The Royal Marsden Hospital Health Care Assistant Role Assessment and Development Profile (2001) can write on observation charts
must not write on prescription charts, assessment sheets, care plans or progress notes.
Assessment and care planning
1 The first written assessment and the identification of the patient’s immediate needs must begin within 4 hours of admission. This must include any allergies or infection risks of the patient and the contact details of the next of kin.
2 The following must be completed within 24 hours of admission and updated as appropriate:
nutritional, oral, pressure sore and manual handling risk assessments
other relevant assessment tools, for example pain and wound assessment.
3 All sections of the nursing admission assessment must be completed at some point during the patient’s hospital stay with the identification of the patient’s care needs. If it is not relevant or if it is inappropriate to assess certain functional health patterns, for example the patient is unconscious, then indicate the reasons accordingly.
The ongoing nursing assessment should identify whether the patient’s condition is stable, has deteriorated or improved.
4 Care plans should be written wherever possible with the involvement of the patient, in terms that they can understand, and include:
patient-focused, measurable, realistic and achievable goals
nursing interventions reflecting best practice
relevant core care plans that are individualized, signed, dated and timed.
5 Update the care plan with altered or additional interventions as appropriate.
6 The nursing documentation must be referred to at shift handover so it needs to be kept up to date.
Principles of assessment
Assessment should be a systematic, deliberate and interactive process that underpins every aspect of nursing care (Heaven and Maguire 1996).
Assessment should be seen as a continuous process (Cancer Action Team 2007).
Structure of assessment
The structure of a patient assessment should take into consideration the specialty and care setting and also the purpose of the assessment.
When caring for individuals with cancer, assessment should be carried out at key points during the cancer pathway and dimensions of assessment should include background information and assessment preferences, physical needs, social and occupational needs, psychological well-being and spiritual well-being (Cancer Action Team 2007).
Functional health patterns provide a comprehensive framework for assessment, which can be adapted for use within a variety of clinical specialties and care settings (Gordon 1994).
Methods of assessment
Methods of assessment should elicit both subjective and objective assessment data.
An assessment interview must be well structured and progress logically in order to facilitate the nurse’s thinking and to make the patient feel comfortable in telling their story.
Specific assessment tools should be used, where appropriate, to enable nurses to monitor particular aspects of care, such as symptom management (e.g. pain, fatigue), over time. This will help to evaluate the effectiveness of nursing interventions whilst often providing an opportunity for patients to become more involved in their care (Conner and Eggert 1994).
Decision making and nursing diagnosis
Nurses should be encouraged to provide a rationale for their clinical judgements and decision making within their clinical practice (NMC 2009).
The language of nursing diagnosis is a tool