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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 ...
Levine postulated four main principles that the nurse follow to facilitate healing a patient. They are conserving the patient's: Energy; Structural integrity; Personal integrity; Social integrity; The conservation model of nursing is based around the law of conservation of energy, combined with the psycho-social aspects of the individual's ...
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.
In healthcare, Carper's fundamental ways of knowing is a typology that attempts to classify the different sources from which knowledge and beliefs in professional practice (originally specifically nursing) can be or have been derived. It was proposed by Barbara A. Carper, a professor at the College of Nursing at Texas Woman's University, in 1978.
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. The diagnosis phase was ...
The GRADE approach separates recommendations following from an evaluation of the evidence as strong or weak. A recommendation to use, or not use an option (e.g. an intervention), should be based on the trade-offs between desirable consequences of following a recommendation on the one hand, and undesirable consequences on the other.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
The second two levels form a taxonomy in which each intervention is grouped into 27 classes, and each class is grouped into six domains. An intent of this structure is to make it easier for a nurse to select an intervention for the situation, and to use a computer to describe the intervention in terms of standardized labels for classes and domains.