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2. Nursing care plan - Wikipedia

   en.wikipedia.org/wiki/Nursing_care_plan

   A nursing care plan provides direction on the type of nursing care the individual/family/community may need. [1] The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. [2] Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the ...

3. Consolidated Clinical Document Architecture - Wikipedia

   en.wikipedia.org/wiki/Consolidated_Clinical...

   The HL7 Consolidated Clinical Document Architecture ( C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1] [2] [3] All certified Electronic health records in the United States are required to ...

4. Clinical Care Classification System - Wikipedia

   en.wikipedia.org/wiki/Clinical_Care...

   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.

5. Roper–Logan–Tierney model of nursing - Wikipedia

   en.wikipedia.org/wiki/Roper–Logan–Tierney...

   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 ...

6. Advance care planning - Wikipedia

   en.wikipedia.org/wiki/Advance_care_planning

   Advance care planning. Advance care planning is a process that enables individuals with decisional mental capacity to make plans about their future health care. [1] Advance care plans provide direction to healthcare professionals when a person is not in a position to make and/or communicate their own healthcare choices.

7. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   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 ...