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  2. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The plan is what the health care provider will do to treat the patient's concerns—such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. [14] The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters.

  3. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5] Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6]

  4. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    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 ...

  5. Clinical Care Classification System - Wikipedia

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

    Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions.

  6. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]

  7. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are ...

  8. Health assessment - Wikipedia

    en.wikipedia.org/wiki/Health_assessment

    Health assessment has been separated by authors from physical assessment to include the focus on health occurring on a continuum as a fundamental teaching. [8] In the healthcare industry it is understood health occurs on a continuum, so the term used is assessment but may be preference by the speciality's focus such as nursing, physical therapy, etc.

  9. Home health nursing - Wikipedia

    en.wikipedia.org/wiki/Home_health_nursing

    Patient is under the care of a doctor, and getting services under a plan of care established. [13] A doctor certifies that the patient needs, one or more of the following: intermittent skilled nursing care, physical therapy, speech-language pathology, and continued occupational therapy [13]

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