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APA style (also known as APA format) is a writing style and format for academic documents such as scholarly journal articles and books. It is commonly used for citing sources within the field of behavioral and social sciences , including sociology, education, nursing, criminal justice, anthropology, and psychology.
During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5] Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6]
The latest edition is the seventh, which lists over 40,000 terms and was published in 2005. [ 2 ] The book has been reviewed by publications including the American Journal of Occupational Therapy , [ 3 ] Gastroenterology Nursing , [ 4 ] Annals of the Rheumatic Diseases , [ 5 ] Hospitals & Health Networks , [ 6 ] and Hospital Topics .
Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...
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.
An assignment cover sheet is a paper used by students when completing assignments at university for their courses. These coversheets generally contain metadata about the assignment (such as the name of the student and the course number). This aids the efficient handling of assignments.
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 patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...