REPUBLIC ACT NO.

9173 profession conferred by a college or university duly

recognized by the Government:

Philippine Nursing Act of 2002

d) Have at least ten (10) years of continuous
 AN ACT PROVIDING FOR A MORE practice of the profession prior to appointment:
RESPONSIVE NURSING PROFESSION, Provided, however, That the last five (5) years of
REPEALING FOR THE PURPOSE which shall be in the Philippines; and
REPUBLIC ACT NO. 7164, OTHERWISE
KNOWN AS “THE PHILIPPINE NURSING e) Not have been convicted of any offense involving
ACT OF 1991” AND FOR OTHER moral turpitude;
PURPOSES. Requirements Upon Qualification as Member of
the Board of Nursing

ARTICLE II DECLARATION OF POLICY • Any person appointed as Chairperson or Member

of the Board shall immediately resign from any
• It is hereby declared the policy of the State to teaching position in any school, college, university
assume responsibility for the protection and or institution offering Bachelor of Science in
improvement of the nursing profession by instituting Nursing and/or review program for the local nursing
measures that will result in relevant nursing board examinations or in any office or employment
education, humane working conditions, better in the government or any subdivision, agency or
career prospects and a dignified existence for our instrumentality thereof, including government-
nurses. owned or controlled corporations or their
subsidiaries as well as those employed in the
private sector.
ARTICLE III ORGANIZATION OF THE BOARD
Term of Office
OF NURSING
• The Chairperson and Members of the Board shall
hold office for a term of three (3) years and until
Creation and Composition of the Board their successors shall have been appointed and
qualified: Provided, That the Chairperson and
• Composed of a Chairperson and six (6) members. Members of the Board may be reappointed for
They shall be appointed by the President of the another term.
Republic of the Philippines from among two (2)
recommendees, per vacancy, of the Professional Compensation of Board Members
Regulation Commission,here in after referred to as
• The Chairperson and Members of the Board shall
the Commission, chosen and ranked from a list of
receive compensation and allowances comparable
three (3) nominees, per vacancy, of the accredited
to the compensation and allowances received by
professional organization of nurses in the
the Chairperson and members of other professional
Philippines who possess the qualifications
regulatory boards.
prescribed in Section 4 of this Act.
Powers and Duties of the Board
Qualifications of the Chairperson and Members
of the Board (a) Conduct the licensure examination for nurses;
a) Be a natural born citizen and resident of the (b) Issue, suspend or revoke certificates of
Philippines; registration for the practice of nursing;
b) Be a member of good standing of the accredited (c) Monitor and enforce quality standards of nursing
practice in the Philippines and exercise the powers
professional organization of nurses;
necessary to ensure the maintenance of efficient,
c) Be a registered nurse and holder of a master’s ethical and technical, moral and professional
degree in nursing, education or other allied medical standards in the practice of nursing taking into
account the health needs of the nation
 • (b) Commission or toleration of irregularities in the
licensure examination; and
• (d) Ensure quality nursing education by examining
the prescribed facilities of universities or colleges of • (c) Unprofessional, immoral or dishonorable
nursing or departments of nursing education and
ARTICLE IV
those seeking permission to open nursing courses
to ensure that standards of nursing education are EXAMINATION AND REGISTRATION
properly complied with and maintained at all times.
The authority to open and close colleges of nursing
and/or nursing education programs shall be vested Licensure Examination
on the Commission on Higher Education upon the
written recommendation of the Board; All applicants for license to practice nursing shall
be required to pass a written examination, which
(e) Conduct hearings and investigations to resolve shall be given by the Board in such places and
complaints against nurse practitioners for unethical dates as may be designated by the Commission:
and unprofessional conduct and violations of this Provided, That it shall be in accordance with
Act, or its rules and regulations and in connection Republic Act No. 8981, otherwise known as the
therewith, issue subpoena ad testificandum and “PRC Modernization Act of 2000.”
subpoena duces tecum to secure the appearance
of respondents, and witnesses and the production
of documents and punish with contempt persons
Ratings
obstructing, impeding and/or otherwise interfering
with the conduct of such proceedings, upon In order to pass the examination, an examinee
application with the court; must obtain a general average of at least seventy-
five percent (75%) with a rating of not below sixty
(f) Promulgate a Code of Ethics in coordination
percent (60%) in any subject. An examinee who
and consultation with the accredited professional
obtains an average rating of seventy-five percent
organization of nurses within one (1) year from the
(75%) or higher but gets a rating below sixty
effectivity of this Act;
percent (60%) in any subject must take the
(g) Recognize nursing specialty organizations in examination again but only in the subject or
coordination with the accredited professional subjects where he/she is rated below sixty percent
organization; and (60%). In order to pass the succeeding
examination, an examinee must obtain a rating of
(h) Prescribe, adopt, issue and promulgate at least seventy-five percent (75%) in the subject or
guidelines, regulations, measures and decisions as subjects repeated.
may be necessary for the improvement of the
nursing practice, advancement of the profession
and for the proper and full enforcement of this Act
Oath
subject to the review and approval by the
Commission. All successful candidates in the examination shall
be required to take an oath of profession before the
Board or any government official authorized to
Removal or Suspension of Board Members administer oaths prior to entering upon the nursing
practice.
The President may remove or suspend any
member
of the Board after having been given the
opportunity
ARTICLE V
to defend himself/herself in a proper administrative
NURSING EDUCATION
investigation, on the following grounds:
Nursing Education Program
• (a) Continued neglect of duty or incompetence;
• The nursing education program shall provide Studies for Nursing Manpower Needs,
sound general and professional foundation for the Production, Utilization and Development.
practice of nursing.
• The Board, in coordination with the accredited
professional organization and appropriate
government or private agencies shall initiate,
undertake and conduct studies on health human
ARTICLE VI resource production, utilization and development.

NURSING PRACTICE

Scope of Nursing Funding for the Comprehensive Nursing

Specialty Program
A person shall be deemed to be practicing nursing
within the meaning of this Act when he/she singly • The annual financial requirement needed to train
or in collaboration with another, initiates and at least ten percent (10%) of the nursing staff of the
performs nursing services to individuals, families participating government hospital shall be
and communities in any health care setting. It chargeable against the income of the Philippine
includes, but not limited to, nursing care during Charity Sweepstakes Office and the Philippine
conception, labor, delivery, infancy, childhood, Amusement and Gaming Corporation, which shall
toddler, pre-school, school age, adolescence, equally share in the costs and shall be released to
adulthood and old age the Department of Health subject to accounting
and auditing procedures: Provided, That the
Department of Health shall set the criteria for the
Qualifications of Nursing Service availment of this program.
Administrators
A person occupying supervisory or managerial ARTICLE VIII
positions requiring knowledge of nursing must:
PENAL AND MISCELLANEOUS PROVISIONS
• (a) Be a registered nurse in the Philippines;
• (b) Have at least two (2) years experience in
general nursing service administration; Prohibitions in the Practice of Nursing.

• (c) Possess a degree of Bachelor of Science in • A fine of not less than Fifty thousand pesos
(P50,000,00) nor more than One hundred thousand
Nursing, with at least nine (9) units in management pesos (P100,000.00) or imprisonment of not less
and administration courses at the graduate level; than one (1) year nor more than six (6) years, or
and both, upon the discretion of the court, shall be
imposed upon:
• (d) Be a member of good standing of the
accredited • (a) any person practicing nursing in the
Philippines within the meaning of this Act:
professional organization of nurses;
• (1) without a certificate of registration/professional
license and professional identification card or
special temporary permit or without having been
ARTICLE VII
declared exempt from examination in accordance
HEALTH HUMAN RESOURCE PRODUCTION, with the provision of this Act;or
UTILIZATIONAND DEVELOPMENT
• (2) who uses as his/her own certificates of
registration/professional license and professional
identification card or special temporary permit of
another; or
• (3) who uses an invalid certificate of
registration/professional license, a suspended or
10 KEY PHASES
revoked certificate of registration/professional
license, or an expired or cancelled • Phase I – Work setting scenario analysis
special/temporary permit;
• Phase II – Validation studies of roles and
responsibilities/ Benchmarking Of core
competencies with other
• Phase III- Integrative review of outputs from the
validation strategies.
NURSING CORE COMPETENCY • Phase IV- Consensual Validation of Core
STANDARD 2012 Competency Standards
• Phase V – Conduct of Public hearing
LEGAL BASIS • Phase VI – Promulgation of the Revised and
Modified Core Competency Standards
Article III, section 9 (c) of Republic Act No. 9173 or
the Philippine Nursing Act of 2002, states that the • Phase VII- Printing of the Revised and Modified
Professional Regulatory Board of Nursing is core competency Standards (2012 NNCCS)
empowered to “monitor and enforce quality
standards of nursing practice in the Philippines and • Phase VIII- Training in the implementation of the
exercise the powers necessary to ensure the 2012 National Nursing Core Competency
maintenance of efficient, ethical and technical, Standards
moral and professional standards in the practice of • Phase IX - Implementation of the 2012 National
nursing taking into account the health needs of the Nursing Core Competency Standards
nation.” It is, therefore, incumbent upon the Board
of nursing to take the lead in the improvement and • Phase X – Evaluation of the effectiveness of the
effective implementation of the core competency 2012 National Nursing Core Competency
standards of nursing practice in the Philippines to Standards
ensure safe and quality nursing care, and maintain
integrity of the nursing profession.
CONCEPTUAL FRAMEWORK 2012 NATIONAL
NURSING CORE COMPETENCY STANDARDS
SIGNIFICANCE OF THE 2012 NATIONAL
NURSING CORE COMPETENCY STANDARDS
• Basic Nursing Education Program in the BEGINNING NURSE’S ROLE ON CLIENT CARE
Philippines through the Commission on Higher
• Responsibility 1: Practices in accordance with
Education (CHED).
legal principles and the code of ethics in making
• Competency-based Test Framework as the basis personal and professional judgment.
for the development of course syllabi and test
• Responsibility 2: Utilizes the nursing process in
questions for “entry level” nursing practice in the
the interdisciplinary care of clients that empowers
Philippine Nurse Licensure Examination.
the clients and promotes safe quality care.
• Standards of Professional Nursing Practice in
• Responsibility 3: Maintains complete and up to
various settings in the Philippines.
date recording and reporting system.
• National Career Progression Program (NCPP) for
•Responsibility 4: Establishes collaborative
nursing practice in the Philippines.
relationship with colleagues and other members of
• Any or related evaluation tools in various practice the team to enhance nursing and other health care
settings in the Philippines services.
•Responsibility 5: Promotes professional and hospitalization, but it is not legally binding
personal growth and development document.

BEGINNING NURSE’S ROLE ON MANAGEMENT WHY IS BILL OF RIGHTS IMPORTANT?

AND LEADERSHIP
• Bill of Rights if very important in Health Care
• Responsibility 1: Demonstrates management and because a patient should be able to know what
leadership skills to provide safe and quality care. they have a right to.
• Responsibility 2: Demonstrates accountability for • Patient Bill of Rights Protects both a patient and a
safe nursing practice. hospital.
• Responsibility 3: Demonstrates management and • If there wasn’t a Bill of Rights there would be
many problems if complications were to occur.
leadership skills to deliver health programs and
services effectively to specific client groups in the
community settings
CONCLUSION
• Responsibility 4: Manages a community/village
• Hospitals have many functions to perform,
based health facility /component of a health
including the enhancement of health status, health
program or a nursing service.
promotion, and the prevention and treatment of
• Responsibility 5: Demonstrates ability to lead and injury and disease; the immediate and ongoing care
supervise nursing support staff. and rehabilitation of patients; the education of
health professionals, patients, and the community;
• Responsibility 6: Utilizes appropriate mechanisms
and research. All these activities must be
for networking, linkage building and referrals.
conducted with an overriding concern for the values
and dignity of patients.

BEGINNING NURSE’S ROLE ON RESEARCH

• Responsibility 1: Engages in nursing or health NURSING AS AN ART
related research with or under the Supervision of
an experienced researcher. CARING

• Responsibility 2: Evaluates research study/report • Caring is central to all helping professions, such
utilizing guidelines in the conduct of a written as nursing and enables persons to create meaning
research critique. in their lives.

• Responsibility 3: Applies the research process in

improving client care in partnership with a quality MAJOR INGREDIENTS OF CARING
improvement /quality assurance/nursing audit team.
• KNOWING – understanding the other’s needs and
how to respond to these needs.
PATIENT’S BILL OF RIGHTS • ALTERNATING RHYTHMS – signifies moving
back and forth between the immediate and long-
term meanings of behavior, considering the past.
WHAT IS PATIENT’S BILL OF RIGHTS?
• PATIENCE – enables the other to grow in his own
• A list of patient’s rights. way and time.

• It offers guidance and protection to patients by • HONESTY – includes awareness and openness
stating the responsibilities that a hospital and its to one’s own feelings and a genuineness in caring
staff have toward them and their families during for the other.
• TRUST – involves letting go, to allow the other to • Caring as a philosophical concept and
grow in his own way and own time.
proposes that caring is the human mode of
• HUMILITY – means acknowledging that there is
being, or the “most common, authentic
always more to learn and that learning may come
from any source criterion of humanness”
• HOPE – belief in the possibilities of the other’s
growth
The Six Cs of Caring in Nursing
• COURAGE – the sense of going into the
unknown, informed by insight from past COMPASSION
experiences. • Awareness of one’s relationship to others, sharing
their joys, sorrows, pain and accomplishments.
Participation in the experience of another.

NURSING THEORIES ON CARING

COMPETENCE
• Having the knowledge, judgment, skills, energy,
FIVE VIEWPOINTS OF CARING experience and motivation to respond adequately
to others within the demands of professional
• Caring as a moral imperative
responsibilities.
• Caring as an affect
CONFIDENCE
• Caring as a human trait
• The quality that fosters trusting relationships.
• Caring as an interpersonal relationship Comfort with self, client and family
• Caring as a therapeutic intervention CONSCIENCE
• Moral, ethics and an informed sense of right and
wrong. Awareness of personal responsibility.
Culture Care Diversity and Universality
(Leininger) COMMITMENT
• Caring as nurturing behavior has been present • Convergence between one’s desires and
throughout history and is one of the most critical obligations and the deliberate choice to act in
factors in helping people maintain or regain health. accordance with them.
COMPORTMENT
Theory of Bureaucratic Caring (Ray) • Appropriate bearing, demeanor, dress and
language, that are in harmony with a caring
• Caring in nursing is contextual and is influenced
presence. Presenting oneself as someone who
by the organizational structure.
respects others and demands respect.
• The meaning of caring was further influenced by
role and position a person held.
Nursing as Caring (Boykin and Schoenhofer)
• The purpose of the discipline and profession of
Caring, the Human Mode of Being (Roach)
nursing is to know persons and nurture them as a
person’s living in caring and growing in caring.
• Caring in nursing is “an altruistic, active
expression of love, and is the intentional and
CHAPTER III
embodied recognition of value and connectedness”
PROCESSING OF PERSONAL INFORMATION

Theory of Human Care (Watson)

General Data Privacy Principles
• Views caring as the essence and the moral
• The processing of personal information shall be
ideal of nursing.
allowed, subject to compliance with the
• Human care is the basis for nursing’s role in requirements of this Act and other laws allowing
disclosure of information to the public and
society, nursing contribution to society lies in
adherence to the principles of transparency,
its moral commitment to human care. legitimate purpose and proportionality.

Theory of Caring (Swanson) CHAPTER IV

• Caring is a nurturing ways of relating to a valued RIGHTS OF THE DATA SUBJECT

“other”, toward whom one feels a personal sense of
commitment and responsibility
Rights of the Data Subject
• The theory focuses on caring processes as
nursing interventions (a) Be informed whether personal information
pertaining to him or her shall be, are being or have
been processed;
The Primacy of Caring (Benner and Wrubel)
(b)Be furnished the information indicated hereunder
• Nursing is described as a relationship in which before the entry of his or her personal information
caring is primary because it sets up the possibility into the processing system of the personal
of giving and receiving help. information controller, or at the next practical
opportunity:
• Caring facilitates the nurse’s ability to problem
solve and to implement individualized solutions
CHAPTER VIII

REPUBLIC ACT NO. 10173 PENALTIES

• Unauthorized Processing of Personal
DATA PRIVACY ACT OF 2012
Information and Sensitive Personal
.•Concealment of Security Breaches Involving
REPUBLIC ACT NO. 10173 Sensitive Personal Information.
• AN ACT PROTECTING INDIVIDUAL PERSONAL • Malicious Disclosure
INFORMATION IN INFORMATION AND
COMMUNICATIONS SYSTEMS IN THE • Unauthorized Disclosure.
GOVERNMENT AND THE PRIVATE SECTOR, • Combination or Series of Acts
CREATING FOR THIS PURPOSE A NATIONAL
PRIVACY COMMISSION, AND FOR OTHER
PURPOSES
 Love of God
Caring
Integrity
Excellence
Nationalism

PHILIPPINE PROFESSIONAL OBJECTIVES

NURSING ROADMAP • Develop dynamic leaders and provide
opportunities for innovative management in
education, training and research.
PROFESSIONAL REGULATORY BOARD OF
• Ensure adherence to professional, ethical and
NURSING
legal standards for the health and safety of the
Adopting “The Philippine Professional Nursing public.

Roadmap 2030: AProgram of Good • Practice good governance to sustain participative

efforts among nurses and nursing organizations.
Governance of the Nursing Profession.”
• Maintain linkages with domestic and international
stakeholders.
VISION • Sustain growth and productivity that improve the
quality of life of nurses, the Filipino and the people
of world.
Philippine Professional Nursing Care: The
BEST for the Filipino and the Choice of World
by 2030 NURSING PROCESS

MISSION 🞇 A systematic, rational method of planning and

providing individualized nursing care.

We, the Filipino nurses responding to the needs 🞇 An organized sequence of problem- solving
of society, are engaged in providing human and steps used to identify and to manage the health
globally competent nursing care. problems of clients.

CORE VALUES PURPOSE OF NURSING PROCESS

🞇 To identify a client’s health status and actual or
potential health problems or needs.
🞇 Initial Comprehensive Assessment
🞇To establish plans to meet the identified needs.
🞇 Problem-focused Assessment
🞇To deliver specific nursing interventions to meet
🞇Emergency Assessment
those needs.
🞇Time-lapsed Reassessment

CHARACTERISTICS OF
Collection of Data
THE NURSING PROCESS
▪ Data collection is the processof gathering
🞇 Cyclic and dynamic
information about a client’s health status.
🞇 Client centeredness
▪ It includes the health history, physical
🞇 Focus on problem-solving and decision making examination, results of Laboratory and diagnostic
tests and material contributed by other health
🞇 Interpersonal and collaborative style
personnel.
🞇 Universal applicability
🞇 Use of critical thinking

Types of Data
BENEFITS OF NURSING PROCESS
🞇 Provides an orderly &systematic method for
1. Subjective Data
planning &providing care
▪ Also referred to as symptoms or covert data,
🞇 Enhances nursing efficiency by standardizing
nursing practice are apparent only to the person affected and
🞇 Facilitates documentation of care can be described only by that person.
🞇 Provides a unity of language for the nursing
profession
2. Objective Data
🞇 Stresses the independent function of nurses
▪ Also referred to as signs orovert data.
🞇 Increases care quality through the use of
▪ Detectable by an observe or can be measured or
deliberate actions.
tested against an accepted standard.
▪ Can be seen, heard, felt or smelled and they are
ASSESSMENT obtained by observation or physical examination.
🞇 The first and most critical phase of the nursing
process.
Sources of Data
🞇 Defined as a systematic and continuous
1. Primary
collection, organization, validation and
documentation of data • Direct source of information
🞇 Ongoing and continuous throughout all Phases • The client is the primary source of data
of the nursing process.
2. Secondary
• Indirect source of information all sources
Four Types of Assessment
other than the client
• Include: Family members, health Documentation of Data
professionals, records and reports, 🞇 Nurse records client data
laboratory and diagnostic results. 🞇Forms the database for the entire nursing
process and provides data for all other members of
the health care team.
🞇 Accurate documentation is essential and should
Data Collection Methods include all data collected about the client’s health
status.
🞇 Observation
🞇 Interview
DIAGNOSIS
🞇Examination
🞇 The second phase of the nursing process
🞇 The nurse used critical thinking skills to
Interpret assessment data to identify client
problems.
NURSING DIAGNOSIS
Stages of an Interview
🞇 A clinical judgment concerning a human
1. The Opening or Introduction response to health conditions/life processes, or a
2. The Body vulnerability for that responses, by an individual,
family, group or community.
3. The Closing

TYPES OF NURSING DIAGNOSES

ORGANIZATION OF DATA

1. Actual diagnosis
🞇 The nurse uses a format that organizes the
2. Risk diagnosis
Assessment data systematically.
3. Wellness diagnosis
🞇 Often referred to as nursing health history
4. Possible nursing diagnosis
or nursing assessment form.
5. Syndrome diagnosis

Validation of Data
COMPONENTS OFA NANDA
🞇 The information gathered during the assessment
is “double-checked” or verified to Confirm that it is NURSING DIAGNOSES
accurate and complete. 1. Problem (Diagnostic Label) and Definition
🞇 CUES–subjective or objective data that can be 2. Etiology (Related Factorsand RiskFactors)
directly observed by the nurse; what the client says
or what the nurse can see, 3. Defining Characteristics

🞇 INFERENCES –nurse’s interpretation or

Conclusions made based on the cues Nurses Function
🞇 Independent Functions- the areas of health care Formal Nursing Care Plan
that are unique to nursing and separate and distinct
🞇 A written or computerized guide that
from medical management
organizes information about the client’s
🞇 Dependent Functions–Physician-prescribed
therapies and treatment care.

DIAGNOSTIC PROCESS Standardized Care Plan

🞇 Analyzing data 🞇 Formal plan that specifies the nursing care for
groups of clients with common needs.
🞇 Identifying health problems, risks
and strengths
Individualized Care Plan
🞇Formulating diagnostic statement
🞇 Tailored to meet the unique needs of a specific
client

PLANNING
🞇 A deliberative, systematic phase of the nursing
IMPLEMENTING
process that involves decision making and
problem-solving. 🞇 Action phase in which the nurse performs the
nursing intervention
🞇 Consists of doing and documenting the activities
TYPES OF PLANNING
that are the specific nursing actions needed to carry
Initial Planning out the interventions.
🞇 Done after the initial assessment
Ongoing Planning IMPLEMENTING SKILLS
🞇 Done by all nurses who work with the client. Cognitive Skills (Intellectual Skills)
🞇 Ongoing planning occurs at the beginning of a 🞇 Include problem-solving, decision
shift as the nurse plans the care to be given that
making, critical thinking and creativity
day

Interpersonal Skills
Discharge Planning
🞇 All the activities, verbal and nonverbal,
🞇 Process of anticipating and planning for Needs
after discharge. people use when interacting directly with
one another.
Informal Nursing Care Plan
🞇 A strategy for action that exists in the nurse’s Technical Skills
mind.
🞇 Purposeful “hands-on” skills such as
manipulating equipment, giving injections,
bandaging, moving, lifting and repositioning clients
 Nursing Audit
PROCESS OF IMPLEMENTING 🞇 Audit means the examination or review of
records.
🞇 Retrospective audit is the evaluation of a client’s
🞇 Reassessing the client
record after discharge from an agency.
🞇 Determining the nurse’s need for assistance
🞇 Concurrent audit is the evaluation of a client’s
🞇 Implementing the nursing interventions health care while the client is still receiving care
from the agency.
🞇 Supervising the delegated care
🞇 Documenting nursing activities
DOCUMENTATION & REPORTING
🞇 Discussion –informal oral consideration of a
subject by two or more health care personnel to
identify a problem or establish strategies to solve a
problem.
🞇 Report–oral, written, or computer-based
communication intended to convey information to
others.

EVALUATING
🞇 Planned, ongoing, purposeful activity in which
clients and healthcare professionals determine: Purposes of Client Records
a. The client’s progress toward achievements 🞇 Communication
of goals/outcomes. 🞇 Planning Client Care
b. The effectiveness of the nursing care plan. 🞇 Auditing Health Agencies
🞇 Research
EVALUATING THE QUALITY OF NURSING 🞇 Education
CARE
🞇 Reimbursement
🞇 Legal Documentation
Quality Assurance
🞇 HealthCare Analysis
🞇 Ongoing, systematic process designed to
evaluate and promote excellence in the health care
provided to clients. SOURCE-ORIENTED RECORD
🞇 The traditional client record.
Quality Improvement 🞇 Each person or department makes notations in a
🞇 Evaluating and improving the quality of health separate section or sections of the client’s chart
care based on internal assessment by health care
providers and increasing awareness by the public
in medical errors are notuncommon and can be
lethal.
PROBLEM-ORIENTED MEDICALRECORD
(POMRorPOR)
🞇 The data are arranged according tothe SOAP,SOAPIE, SOAPIER, APIE
problemsthe client has ratherthan the 🞇 S Subjective Data
source of the information. 🞇 O Objective Data
🞇 Four basic components: 🞇 A Assessment
🞇 Database 🞇 P Plan
🞇 Problemlist 🞇 I Interventions
🞇 Plan ofcare 🞇 E Evaluations
🞇 Progressnotes 🞇 R Revision

Database
🞇 Consists of all information known about the client
when the client first enters the health care agency.
🞇 Includes the nursing assessment, the physician’s
history, social and family data and the results of the
physical examination and baseline diagnostic tests.

Problem List
🞇 Derived from the database
🞇 Listed in the order in which they are identified,
and the list is continually updated as new problems
are identified and others resolved.

Plan of Care
🞇 The initial list of orders or plan of care is made
with reference to the active problems.
🞇 Generated by the person who lists the problems.
🞇 Nurses write nursing orders or nursing care
plans.

Progress Note
🞇 A chart entry made by all health professional
involved in a client’s care.
🞇 Are numbered to correspond to the problems on
the problem list and may be lettered for the type of
data.