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An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
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]
Nursing credentials and certifications are the various credentials and certifications that a person must have to practice nursing legally. Nurses' postnominal letters (abbreviations listed after the name) reflect their credentials—that is, their achievements in nursing education, licensure, certification, and fellowship.
Once certified, the Wisconsin Board of Nursing recognizes the individual as competent to practice as an APRN. The Wisconsin Board of Nursing also regulates licensure as an Advanced Practice Nurse Prescriber (APNP). In order to obtain licensure as an APNP, the above credentials must be obtained first (RN licensure and certification as an APRN).
Physicians are generally required to generate at least one progress note for each patient encounter. 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 ...
The Nursing Minimum Data Set became the basis for the nursing classification standards recognized by the ANA. [8] In 1990, the CCAIN was renamed the Database Steering Committee. In 1991, the Database Steering Committee submitted to the Congress on Nursing Practice a resolution that NI be adopted as a new nursing specialty.
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[5] This is because at every change of shift, there is a chance for miscommunication about vital patient information. [1] 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.