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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
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.
In healthcare, Carper's fundamental ways of knowing is a typology that attempts to classify the different sources from which knowledge and beliefs in professional practice (originally specifically nursing) can be or have been derived. It was proposed by Barbara A. Carper, a professor at the College of Nursing at Texas Woman's University, in 1978.
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]
In the social sciences, the term "normative" has broadly the same meaning as its usage in philosophy, but may also relate, in a sociological context, to the role of cultural 'norms'; the shared values or institutions that structural functionalists regard as constitutive of the social structure and social cohesion.
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
PICOT formatted questions address the patient population (P), issue of interest or intervention (I), comparison group (C), outcome (O), and time frame (T). Asking questions in this format assists in generating a search that produces the most relevant, quality information related to a topic, while also decreasing the amount of time needed to produce these search results.
The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1] [2] [3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics. The diagnosis phase was ...