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SUMMARY, CONCLUSIONS, RECOMMENDATIONS AND INSIGHTS

SUMMARY: In function 3 of the nursing audit, it yielded an excellent result since it supervising or taking care of the patient was the goal of the treatment. It was shown in the chart that continuous assessment was done to the patient and actions initiated were related to patient safety and in accordance with his assessment findings. Involving the significant others in patient care was also emphasized in the chart. In function 6, it yielded a good result since the different actions/procedures done by the nurse were documented not only in the SOAP charting but is also seen in the TPR and medication administration sheets. Personal hygiene and care was done prior to going in the operating room. This has yielded a good result since most of these aspects belong to the physiologic needs of the patient and according to Maslows hierarchy of needs, physiological needs is the priority. Functions 1, 2 5 and 7 had yielded an incomplete result since some physicaians orders were confusing and some does not include any time or date. Also upon the admission of the patient, no clear history was taken by the nurse and only the present condition of the patient was shown and no comprehensive assessment of the history was done. Only little attention was given to reporting and recording the facts to the physician and encouraging the patient to report any untoward signs to the physician or nurse, only 1 statement encourages the patient to verbalize his concerns(instructed patient to report signs of pain). No data were recorded showing that nurses report to the doctors important assessment findings/ essential facts. There was a lack of documentation of specific teaching on what to do during an emergency situation. It was also documented that there was an encouragement in verbalization of feelings and concerns of the patient but none for the family members which was considered essential. Specific interventions for specific problem however were done by the health care team to address the situation. No assessment was done if the patient needed outside resources such as spiritual guidance, social services, or occupational therapy. Only the discharge instruction was given to the patient about medications and followup check-up. Function 4 yielded a poor result since most of its aspects were not done as seen in the patients chart. No evidence shows that support and continuity of supervision was being done to those taught by the nurses. This function shows that health teachings were done with the patient for the improvement of his condition as shown in the SOAP charting by the nurses and student nurses. Overall, it yielded a good result, with this it implies that the chart is at least complete and with the appropriate information.

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