In relation to documentation, The Joint Commission (TJC) standards require
a. a traditional nursing care plan
b. documentation of all steps of the nursing process
c. interdisciplinary planning and implementation of all aspects of care
d. patient signature on nursing records
C
The Joint Commission no longer requires that health care organizations have traditional nursing care plans but documentation of an individualized plan of care must be evident for each patient. TJC requires the involvement of the patient or family in the development of the plan, which must be documented in the medical record, and interdisciplinary planning and implementation of all aspects of care.
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