Standard 2. Diagnosis The registered nurse analyzes the assessment data to determine the diagnosis or the issues.
Definition and Purpose Diagnosis uses standard language to name health problems in order to: Develop a plan of care and evaluate its outcomes Communicate with healthcare providers Differentiate among and educate healthcare practitioners Organize research to develop discipline’s body of knowledge Organize practice quality evaluation and improvement System for reimbursement for healthcare services
Types of Diagnoses Used in Nursing Statements of actual or potential response to a health problem experienced by a patient, family, or community. Terms used to identify the genetic and pathological conditions, illnesses, and syndromes that cause patient’s signs and symptoms. Terms used to identify health problems encountered within communities and system problems within healthcare organizations.
Diagnostic Processes Use of clinical judgment Analysis of assessment data Knowledge of potential diagnoses Use of pattern recognition and deductive reasoning to match data to best diagnosis Confirmation of diagnosis based on collection of additional data and reassessment