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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...

  3. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.

  4. Acts Retirement-Life Communities - Wikipedia

    en.wikipedia.org/wiki/ACTS_Retirement-Life...

    Acts Retirement-Life Communities (Acts), based out of Fort Washington, Pennsylvania, is the third largest not-for-profit owner, operator and developer of continuing care retirement communities (CCRCs) in the United States. [1]

  5. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

  6. Clinical documentation improvement - Wikipedia

    en.wikipedia.org/wiki/Clinical_documentation...

    Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...

  7. 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.

  8. Change-of-shift report - Wikipedia

    en.wikipedia.org/wiki/Change-of-shift_report

    A specific type of change-of-shift report is Nursing Bedside Shift Report in which the off going nurse provides change-of-shift report to the on coming nurse at the patient's bedside. [ 1 ] [ 6 ] [ 7 ] Since 2013, giving report at the patient bedside has been recommend by the Agency for Healthcare Research and Quality (AHRQ) to improve patient ...

  9. Nursing home - Wikipedia

    en.wikipedia.org/wiki/Nursing_home

    In 2002, nursing homes became known as care homes with nursing, and residential homes became known as care homes. [31] As of April 2009, the lower capital limit is £13,500. At this level, all income from pensions, savings, benefits and other sources, except a "personal expenses allowance" (currently £21.90), goes towards paying the care home ...