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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 ...
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...
The Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, and Allied Health is written for use by students and health care providers including medics, nurses, and paramedics. The entries are alphabetical and compiled with multidisciplinary collaboration. Illustrations and tables were included from the sixth edition. [1]
Prehospital care providers such as emergency medical technicians may use the same format to communicate patient information to emergency department clinicians. [5] Due to its clear objectives, the SOAP note provides physicians a way to standardize the organization of a patient's information to reduce confusion when patients are seen by various ...
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
The 8th edition, published in 2009, contains 2,240 pages and 2,400 colour illustrations. It includes some encyclopaedic definitions and 12 appendixes containing reference information. [1] Earlier versions are titled Mosby's Medical, Nursing & Allied Health Dictionary. [2]
The Journal of Nursing Management is a bi-monthly peer-reviewed journal covering advances in the discipline of nursing management and leadership. It was established in 1993 by Anthony Palmer, [1] and is published by John Wiley & Sons. The journal is currently edited by Fiona Timmins (Trinity College Dublin). [2]