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The following areas are assessed through questions asked by the nurse and medical examinations to provide an overview of the individual's health status and health practices that are used to reach the current level of health or wellness. [1] [2] Health Perception and Management; Nutritional metabolic
For this reason, it is not recommended in the model that it be used as a checklist, but rather as Roper states "As a cognitive approach to the assessment and care of the patient, not on paper as a list of boxes, but in the nurse's approach to and organisation of their care" [3] and that nurses in clinical practice deepen their knowledge and ...
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 Global Appraisal of Individual Needs (GAIN) is a family of evidence-based instruments used to assist clinicians with diagnosis, placement, and treatment planning. The GAIN is used with both adolescents and adults in all kinds of treatment programs, including outpatient, intensive outpatient, partial hospitalization, methadone, short-term residential, long-term residential, therapeutic ...
A performance appraisal, also referred to as a performance review, performance evaluation, [1] (career) development discussion, [2] or employee appraisal, sometimes shortened to "PA", [a] is a periodic and systematic process whereby the job performance of an employee is documented and evaluated. This is done after employees are trained about ...
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]
A nursing care component is defined as a cluster of elements that represents a unique pattern of clinical care nursing practice; namely, Health Behavioral, Functional, Physiological, and Psychological. Nursing Diagnoses: A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs.
A broad definition of a nurse-led clinic defines these clinics based on what nursing activities are performed at the site. [4] Nurses within a nurse-led clinic assume their own patient case-loads, provide an educative role to patients to promote health, provide psychological support, monitor the patient's condition and perform nursing interventions. [4]