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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
Omaha System. The Omaha System is a standardized health care terminology consisting of an assessment component (Problem Classification Scheme), a care plan/services component (Intervention Scheme), and an evaluation component (Problem Rating Scale for Outcomes). Approximately 22,000 health care practitioners, educators, and researchers use ...
Home care. Homecare (also spelled as home care) is health care or supportive care provided by a professional caregiver in the individual home where the patient or client is living, as opposed to care provided in group accommodations like clinics or nursing home. [1] Homecare is also known as domiciliary care, social care or in-home care.
Mental disorders. Mental health, as defined by the Public Health Agency of Canada, [7] is an individual's capacity to feel, think, and act in ways to achieve a better quality of life while respecting personal, social, and cultural boundaries. [8] Impairment of any of these are risk factor for mental disorders, or mental illnesses, [9] which are ...
The Nursing Interventions Classification ( NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan. The NIC provides a four level hierarchy whose first two levels consists of a list of 433 different ...
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice ...
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