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Nursing care plans provide continuity of care, safety, quality care and compliance. 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 ...
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 ...
Nursing diagnosis. A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions ...
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. [1]
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 ...
The Nursing Outcomes Classification ( NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to ...
Effective therapeutic regimen management. Readiness for enhanced therapeutic regimen management is a NANDA approved nursing diagnosis which is defined as "A pattern of regulating and integrating into daily living a program (s) for treatment of illness and its sequelae that is sufficient for meeting health-related goals and can be strengthened." [1]
Nursing assessment is the gathering of information about a patient 's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
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