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  2. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    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.

  3. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    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 ]

  4. Scope of practice - Wikipedia

    en.wikipedia.org/wiki/Scope_of_practice

    In the United States, scope of practice law is determined by the states' legislatures and regulatory boards. [1] [3]According to the National Conference of State Legislatures, non-physician health care providers are providing increasing levels of service to patients, especially in rural and other underserved communities.

  5. Statement of work - Wikipedia

    en.wikipedia.org/wiki/Statement_of_work

    The master service agreement serves as a master contract governing the terms over potentially multiple SOWs. Sometimes it refers to scope of work. For instance, if a project is done on contract, the scope statement included as part of it can be used as the SOW since it also outlines the work of the project in clear and concise terms. [3]

  6. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    The CCC System was developed from retrospective research data from 8,967 patient records from a sample of 800 organizations randomly stratified by staff size, type of ownership, and geographic location. [26] The methodology was applied to a national sample of home health agencies that provided all services and products (Spradley & Dorsey, 1985 ...

  7. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

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  9. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    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.