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2. Nursing assessment - Wikipedia

   en.wikipedia.org/wiki/Nursing_assessment

   Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.

3. Gordon's functional health patterns - Wikipedia

   en.wikipedia.org/wiki/Gordon's_functional_health...

   Cognitive-perceptual-assessment of neurological function is done to assess, check the person's ability to comprehend information; Self perception/self concept; Role relationship—This pattern should only be used if it is appropriate for the patient's age and specific situation. Sexual reproductivity; Coping-stress tolerance; Value-Belief Pattern

4. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving ...

5. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be required anywhere from several times an hour to several times a day.

6. Admission note - Wikipedia

   en.wikipedia.org/wiki/Admission_note

   see Physical examination#Example: labs and diagnostics studies "none" May cover studies performed at an outside hospital, during prior admissions, or in the ER before the current admission. assessment and plan (A&P) "Pt is a 30 yo female..." Assessment and plan are very closely related, and are often reported in a single section.

7. Nursing care plan - Wikipedia

   en.wikipedia.org/wiki/Nursing_care_plan

   Client assessment, medical results and diagnostic reports. This is the first step in order to be able to create a care plan. In particular client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic and environmental.