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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
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.
The main ones are the "headings" (also known as MeSH headings or descriptors [2]), which describe the subject of each article (e.g., "Body Weight", "Brain Edema" or "Critical Care Nursing"). Most of these are accompanied by a short description or definition, links to related descriptors, and a list of synonyms or very similar terms (known as ...
A group of scientists, doctors, clergy, and consumers that reviews and approves the action plan for every clinical trial. There is an Institutional Review Board at every health care facility that does clinical research. Institutional Review Boards are designed to protect the people who take part in a clinical trial.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
The single most important feature of any article is lucidity. Useful guidelines are to write in fairly short sentences, keeping the words and phrases as simple as possible. Reading the article aloud is a good way of discovering how intelligible it is and some authors normally write their first drafts by using a tape recorder.
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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]