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Nursing diagnosis. A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions ...
Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient. The following areas are assessed through questions asked by the nurse and medical examinations to provide an overview of the individual's health status and ...
Nanda.org. NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnosis. In 2002, NANDA ...
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1][2][3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics.
diagnosis; change: ΔΔ: differential diagnosis (the list of possible diagnoses, and the effort to narrow that list) +ve: positive (as in the result of a test) # fracture: #NOF: fracture to the neck of the femur ℞ (R with crossed tail) prescription: Ψ: psychiatry, psychosis: Σ: sigmoidoscopy: x/12: x number of months x/40: x number of weeks ...
The American Nurses Association recognized the Omaha System as a standardized terminology to support nursing practice in 1992. In 2014, Minnesota became the first state to recommend that point-of-care terminologies recognized by the American Nurses Association be used in all electronic health records. The evidence underlying this decision was a ...
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 ...