Search results
Results from the WOW.Com Content Network
You are free: to share – to copy, distribute and transmit the work; to remix – to adapt the work; Under the following conditions: attribution – You must give appropriate credit, provide a link to the license, and indicate if changes were made.
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.
A nursing care component is defined as a cluster of elements that represents a unique pattern of clinical care nursing practice; namely, Health Behavioral, Functional, Physiological, and Psychological. Nursing Diagnoses: A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs.
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...
Mosby's Dictionary of Medicine, Nursing & Health Professions is a dictionary of health-related topics. The 8th edition, published in 2009, contains 2,240 pages and 2,400 colour illustrations. The 8th edition, published in 2009, contains 2,240 pages and 2,400 colour illustrations.
Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
The majority of the medical record consists of progress notes documenting the care delivered and the clinical events relevant to diagnosis and treatment for a patient. They should be readable, easily understood, complete, accurate, and concise.