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  2. Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Minimum_Data_Set

    MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. Participants in the assessment process are health care professionals and direct care staff such as registered nurses , licensed practical or vocational nurses (LPN/LVN), Therapists, Social Services ...

  3. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    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.

  4. Clinical Institute Withdrawal Assessment for Alcohol

    en.wikipedia.org/wiki/Clinical_Institute...

    The Clinical Institute Withdrawal Assessment for Alcohol, commonly abbreviated as CIWA or CIWA-Ar (revised version), is a 10-item scale used in the assessment and management of alcohol withdrawal.

  5. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    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.

  6. Nursing diagnosis - Wikipedia

    en.wikipedia.org/wiki/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 driven by physician ...

  7. Nursing Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Nursing_Minimum_Data_Set

    The Nursing Minimum Data Set (NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations ...

  8. Crowell procedure - Wikipedia

    en.wikipedia.org/wiki/Crowell_procedure

    The Crowell procedure is a tool used to assess the parent-child relationship. [1] Crowell and Feldman created the assessment tool for use in a study. [2] The tool, which includes seven activities for the parent-child dyad to complete, is used for both preventive and clinical purposes. [1]

  9. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.