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Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
Nursing Research Applications: Search online nursing literature for nursing ontology and the CCC System. Research the use of relative value units and the CCC of Nursing Interventions/action Types. Analyze and interpret nursing output in the EHR. Support research to advance NI science and knowledge. Nursing Administration Applications:
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.
The data collected through formal (typically self-report) measurement (like the PHQ-9 for depression [3]) has been used to enhance the accuracy of clinical assessments, provide a basis for treatment planning, deliver an objective methodology for tracking treatment progress, alert therapists with clinically proven guidelines to get refractory cases back on track, help prevent hospitalizations ...
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
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A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
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