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A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. [8] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. [8]
A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care. Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
The plan is what the health care provider will do to treat the patient's concerns—such as ordering further labs, radiological work up, referrals given, procedures performed, medications given and education provided. [14] The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters.
In providing care, nurses implement a nursing care plan defined using the nursing process. This is based around a specific nursing theory that is selected based on the care setting and the population served. In providing nursing care, the nurse uses both nursing theory and best practice derived from nursing research. [59]
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 interventions used in the Nursing Interventions Classification again allow for the use of standardized language which improves consistency of terminology, definition and ability to identify nursing activities, which can also be linked to nursing workload and staffing indices. The result of this phase is a nursing care plan.
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 care plan tailored for specific circumstances is prepared after a comprehensive assessment has taken place, and is continuously monitored and modified as needed. [3] A comprehensive geriatric care assessment is thorough and can take anywhere from two to five hours in length, this of course is broken down into two or three assessment visits ...
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