Assessment
A structured process used to gather information about a persons condition. It helps identify needs and guide care.
Goal
A desired outcome that guides the care plan. Goals help measure progress.
Intervention
An action taken to improve a persons condition. It is based on assessment findings.
Evaluation
A review of progress toward goals. It helps determine if changes are needed.
Care Plan
A written outline of needs goals and interventions. It guides daily care.
Priority
The level of importance assigned to a need. High priority needs require immediate attention.
Outcome
The result of care provided. Outcomes show whether goals were met.
Implementation
The process of carrying out interventions. It requires coordination and communication.
Documentation
A written record of care provided. It ensures continuity and accountability.
Reassessment
A repeat evaluation to check for changes. It helps update the care plan.
Discharge Plan
A plan for care after leaving a facility. It supports safe transitions.
Support System
People who help with emotional or physical needs. A strong support system improves outcomes.
Symptom Management
Actions taken to reduce discomfort. It helps improve quality of life.
Monitoring
Ongoing observation of a persons condition. It helps detect changes early.
Collaboration
Working with others to provide care. It improves outcomes.
Individualized Care
Care tailored to a persons unique needs. It respects preferences and abilities.
Risk Factor
A condition that increases the chance of problems. Identifying risks helps prevent complications.
Strengths
Abilities that support recovery. Recognizing strengths helps build confidence.
Plan of Care Review
A regular check of the care plan. It ensures goals remain appropriate.
Progress Note
A record of changes and responses to care. It helps track improvement.