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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 .
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.
For example, an "OB/GYN" section may be included, including language such as "G3P2, menarche at age 14, LMP 2 weeks ago, regular". family history (FH) "noncontributory" Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase ...
Any pertinent information pertaining to the sample must be included for the reader to judge the study as worthy. In addition, the current evidence-based practice (EBP) movement in healthcare emphasizes that clinical decision making should be based on the "best evidence" available, preferably the findings of randomized clinical trials.
Whole-person specialty care, a model where a comprehensive care team works together to coordinate personalized and individualized treatment, is offering renewed hope for patients.
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 ...
A common stomach bug is surging, according to new data from the US Centers for Disease Control and Prevention. In the week of December 5, there were 91 outbreaks of norovirus reported, up from 69 ...
Hints and the solution for today's Wordle on Thursday, December 12.