A nursing data base for initial patient assessment.

Abstract

The introduction of nursing diagnoses at Saddleback Memorial Medical Center, Laguna Hills, CA, resulted in the nursing process becoming the basis for the documentation system. However, the medical model or body system remained the organizational structure for nursing data collection and narrative charting. The need for a model that would aid in identification and treatment of illness and not negatively affect the nursing process was the impetus behind the selection of Gordon's functional health patterns as the assessment format. These patterns provide a standard method for data collection and a holistic approach to assessment and diagnosis.