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The function of nursing care plans has changed drastically over the past several decades. In 1953, care planning was not believed to be within the nursing scope of practice. [5] In the 1970s, care planning was activity based. [5] Patients were listed according to the procedures they were having done, which determined their plan of care. [5]
"In the United States, certified nursing assistants typically work in a nursing home or hospital and perform everyday living tasks for the elderly, chronically sick, or rehabilitation patients who cannot care for themselves." [11] Many community colleges offer CNA training in one semester. Other educational programs offer accelerated programs.
It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8] Nowadays, the NCP is widely used in nursing in various clinical and educational settings as a tool to direct individualized nursing care for clients.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. 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.
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.
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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.
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.