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Notes on Nursing: What it is and What it is Not is a book first published by Florence Nightingale in 1859. [1] [2] [3] A 76-page volume with 3 page appendix published by Harrison of Pall Mall, it was intended to give hints on nursing to those entrusted with the health of others.
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969), [2] that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic ...
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.
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow ...
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
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 .
Questions on the NCLEX exam are of three different types or levels: Level 1, Level 2, and Level 3. Level 1 questions are the most basic questions and make up less than 10 percent of the total questions. Level 1 questions test the individual's knowledge and understanding. These questions require the individual to recall specific facts and ...