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  2. Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Minimum_Data_Set

    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, Activities and Dietary staff employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in ...

  3. 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.

  4. 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.

  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. 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]

  7. CAGE questionnaire - Wikipedia

    en.wikipedia.org/wiki/CAGE_questionnaire

    The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used screening test for problem drinking and potential alcohol problems.The questionnaire takes less than one minute to administer, [1] and is often used in primary care or other general settings as a quick screening tool rather than as an in-depth interview for those who have alcoholism.

  8. Review of systems - Wikipedia

    en.wikipedia.org/wiki/Review_of_systems

    A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).

  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.