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Peer evaluation is the process of getting feedback on one's specific role competencies or "at work" behaviors from people that one works within the department and from other departments. "Colleague evaluation" is a more appropriate term than "peer evaluation" as this is not a form of professional peer review. [20]
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.
A progress note is considered as containing noise when there is difference between the surface form of the entered text and the intended content. For instance, when a clinician enters "bp" instead of "blood pressure", or an acronym such as "ARF" that could mean "Acute Renal Failure" or "Acute Rheumatic Fever".
An admission form is a fundamental record in nursing documentation. It documents a client's status, reasons why the client is being admitted, and the initial instructions for that client's care. [3] The form is completed by a nurse when a client is admitted to a health care facility.
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 ...
State Enrolled Nurse (UK) – See Licensed Practical Nurse: SHO: Senior house officer (UK) SIGN: Scottish Intercollegiate Guidelines Network (SIGN and NICE are major centers of CPG development) SIOP: International Society of Paediatric Oncology SN: Student nurse SOMA: Student Osteopathic Medical Association: STFM: Society of Teachers of Family ...
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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]
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