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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.
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
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 ...
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.
The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. (The term "swing bed" refers to the Social Security Act's authorizing small, rural hospitals to use their beds in ...
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 ...
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