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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 ...
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence". [1]
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.
Nancy Roper, when interviewed by members of the Royal College of Nursing's (RCN) Association of Nursing Students at RCN Congress in 2002 in Harrogate [5] stated that the greatest disappointment she held for the use of the model in the UK was the lack of application of the five factors listed below, citing that these are the factors which make ...
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.
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use of space; foods; meal preparation and related life ways; Leininger proposes that there are three modes for guiding nursing care judgements, decisions, or actions to provide appropriate, beneficial, and meaningful care: (a) preservation and/or maintenance (b) accommodation and/or negotiation (c) re-patterning and/or restructuring