Search results
Results from the WOW.Com Content Network
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.
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and ...
Nursing A nurse checks a patient's blood pressure. Occupation Activity sectors Nursing Description Competencies Caring for general and specialized well-being of patients Education required Qualifications in terms of statutory regulations according to national, state, or provincial legislation in each country Fields of employment Hospital Clinic Laboratory Research Education Home care Related ...
The crowdsourced learning platform contains practice problems, study guides, infographics, class notes, step-by-step explanations, essays, lab reports, videos, user-submitted questions paired with answers from tutors, and original materials created and uploaded by educators. Users either buy a subscription or upload original documents to ...
Example of informed consent document from the PARAMOUNT trial. Informed consent is a principle in medical ethics, medical law, media studies, and other fields, that a person must have sufficient information and understanding before making decisions about accepting risk, such as their medical care.
Nursing diagnosis Rather than focusing on biological processes, a nursing diagnosis identifies people's responses to situations in their lives, such as a readiness to change or a willingness to accept assistance. Computer-aided diagnosis Providing symptoms allows the computer to identify the problem and diagnose the user to the best of its ability.