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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 .
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
Above: Florence Nightingale, the founder of modern nursing. A registered nurse (RN) is a nurse who has graduated or successfully passed a nursing program from a recognized nursing school and met the requirements outlined by a country, state, province or similar government-authorized licensing body to obtain a nursing license.
In 1988 to 1990, Harriet Werley established the Nursing Minimum Data Set, which consisted of 12 variables: 8 variables focused on patient demographics and the remaining 4 focused on nursing practice. These were (a) nursing diagnoses, (b) nursing interventions, (c) nursing outcomes, and (d) nursing intensity.
Nurse licensure is the process by which various regulatory bodies, usually a Board of Nursing, regulate the practice of nursing within its jurisdiction. The primary purpose of nurse licensure is to grant permission to practice as a nurse after verifying the applicant has met minimal competencies to safely perform nursing activities within nursing's scope of practice.
Eligible candidates must pass an exam, possess a valid RN license and have a graduate-level nursing degree from an accredited acute care advanced practice nursing program. The American Nurses Credentialing Center offers the Adult-Gerontology Acute Care Nurse Practitioner - Board Certified (AGACNP-BC) credential. [ 10 ]
After graduating from a school of nursing, one takes the NCLEX exam to receive a nursing license. A nursing license gives an individual the permission to practice nursing, granted by the state where they met the requirements. NCLEX examinations are developed and owned by the National Council of State Boards of Nursing, Inc. (NCSBN). The NCSBN ...
The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association -recognized terminology, is ...