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The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8]
Effective communication in nursing entails being empathic, non-judgmental, understanding, approachable, sympathetic, caring, and having safe and ethical qualities. [10] The first statement of the CNO Standard is Therapeutic Communication, which explains that a nurse should apply communication and interpersonal skills to create, maintain, and ...
Communication is an enigma that is detrimental to the healthcare world and to the resulting health of a patient. Communication is an activity that involves oral speech, voice, tone, nonverbal body language, listening and more. It is a process for a mutual understanding to come at hand during interpersonal connections.
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]
SBAR is a model used in communication that standardizes information to be given and lessons on communication variability, making report concise, objective and relevant. [ 12 ] Another benefit of using SBAR is that it allows patients to have the time to ask any questions that they might have, and allows patients to gain exact knowledge of ...
Primary nursing is a system of nursing care delivery that emphasizes continuity of care and responsibility acceptance by having one registered nurse (RN), often teamed with a licensed practical nurse (LPN) and/or nursing assistant (NA), who together provide complete care for a group of patients throughout their stay in a hospital unit or department. [1]
Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note, where the note is organized into Subjective, Objective, Assessment, and Plan sections.
The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well. [11] Cyclic and dynamic