La. Admin. Code tit. 46 § XLVII-3903

Current through Register Vol. 50, No. 9, September 20, 2024

Section XLVII-3903 - Standard Number 1: Collection and Recording Individual's Health Status

A. Data concerning an individual's health status must be systematically and continuously collected, recorded, and communicated in order to determine nursing care needs, according to the following criteria.

1. The priority of data collection is determined by the individual's immediate condition and needs.

2. The collection and recording of data provides for systematic collection, frequent updating, accessibility, and appropriate confidentiality.

3. The appropriate data includes:

a. growth and development factors;

b. biophysical status;

c. emotional status;

d. cultural, religious, socioeconomic background;

e. performance of activities of daily living;

f. patterns of coping;

g. interaction patterns;

h. individual's perception of and satisfaction with his health status;

i. individual's health goals;

j. environmental factor (physical, social, emotional, ecological); and

k. available and accessible human and material resources.

4. The data are collected by:

a. interview;

b. examination;

c. observation; and

d. reading of records and reports.

5. The data are collected from:

a. the individual;

b. family members;

c. pertinent others; and

d. other health care personnel.

La. Admin. Code tit. 46, § XLVII-3903

Promulgated by the Department of Health and Human Resources, Board of Nursing, LR 3:309 (July 1977), amended by the Department of Health and Hospitals, Board of Nursing, LR 24:1293 (July 1998).

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:918.