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In 1988 to 1990, Harriet Werley established the Nursing Minimum Data Set, which consisted of 12 variables: 8 variables focused on patient demographics and the remaining 4 focused on nursing practice. These were (a) nursing diagnoses, (b) nursing interventions, (c) nursing outcomes, and (d) nursing intensity.
Studierfenster (StudierFenster) is a free, non-commercial Open Science client/server-based Medical Imaging Processing (MIP) online framework. [51] Medical open network for AI is a framework for Deep learning in healthcare imaging that is open-source available under the Apache Licence and supported by the community. [52]
EditGrid – web-based spreadsheet with charting capabilities; Google Sheets – Online spreadsheet with built-in charting function for basic chart types; KChart – the charting tool of the Calligra Suite; LibreOffice Calc - Built-in charting function for basic chart types; Microsoft Excel – Built-in charting function for basic chart types
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.
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...