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A rapid trauma assessment goes from head to toe to find these life threats: [1] [3] [5] Cervical spinal injury; Level of consciousness; Skull fractures, crepitus, and signs of brain injury; Airway problems (although these were checked during the initial assessment, they are rechecked during the rapid trauma assessment) such as tracheal deviation
Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving ...
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
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.
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.
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U.S. Army General Barbara Holcomb delivering a keynote speech on prolonged field care at the 2017 Military Health System Research Symposium. Prolonged field care refers to the specialized medical care provided to individuals who have sustained injuries or illnesses in situations where timely evacuation to a medical facility (or next tier of healthcare provision) is delayed, challenging, or not ...
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