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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]
A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
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.
These evidence-based guidelines cover topics like fetal heart rate monitoring, labor induction, neonatal skin care, [4] care of the late preterm infant, [5] breastfeeding, HPV counseling, neonatal hyperbilirubinemia, nursing staffing, [6] and care of the patient in the second stage of labor.
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.
The result was a four-part, front-page series that ran from October 23 to 26, 2005, entitled Critical Care: The making of an ICU nurse. [10] The added psychological stress of nursing in critical care units has been well-documented, and it has been argued the stress experienced in ICU areas are unique in the profession. [11]
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 Emergency Nurses Association (ENA) is an international professional organization representing emergency nursing. Consisting of nearly 50,000 members, ENA addresses issues relevant to emergency care, publishes professional guidelines, provides education for emergency nurses and issues a peer-reviewed journal.