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The Nursing Outcomes Classification (NOC) is a classification system which describes client outcomes sensitive to nursing intervention. The Omaha System : The Omaha System is a standardized health care terminology consisting of an assessment component (Problem Classification Scheme), a care plan/services component (Intervention Scheme), and an ...
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charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...
Medical audit later evolved into clinical audit and a revised definition was announced by the NHS Executive: "Clinical audit is the systematic analysis of the quality of healthcare, including the procedures used for diagnosis, treatment and care, the use of resources and the resulting outcome and quality of life for the patient."
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Nursing professionals have historically been less likely to participate or be subject to peer review. [12] [13] This is changing, [16] [15] as is the previously limited extensiveness (for example, no aggregate studies of clinical nursing peer review practices had been published as of 2010) of the literature on nursing peer review [14]
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An early warning system (EWS), sometimes called a between-the-flags or track-and-trigger chart, is a clinical tool used in healthcare to anticipate patient deterioration by measuring the cumulative variation in observations, most often being patient vital signs and level of consciousness. [1]