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A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
Clinical Care Classification System. The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.
Nursing assessment is the gathering of information about a patient 's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse.
The Roper, Logan and Tierney model of nursing (originally published in 1980, and subsequently revised in 1985, 1990, 1998 and the latest edition in 2000) is a model of nursing care based on activities of living (ALs). It is extremely prevalent in the United Kingdom, particularly in the public sector. [ 1 ] The model is named after the authors – Nancy Roper, Winifred W. Logan and Alison J ...
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 workflow starting with appointment scheduling, patient check-in ...
Evidence-based nursing (EBN) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic.
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.
According to a new study, your microwave is one of the dirtiest appliances in your kitchen and can contain tons of bacteria. Here's what you need to know.
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