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The nursing directives can be addressed to nurses, nursing assistants or beneficiary attendants. Each priority problem or need must be followed by a nursing directive or an intervention. The interventions must be specific to the patient. For example, two patients with the problem 'uncooperative care' can need different directives.
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.
In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]
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]
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.
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The scope of practice for a nurse practitioner includes the range of skills, procedures, and processes for which the individual has been educated, trained, and credentialed to perform. [2] Scope of practice for nurse practitioners is defined at four levels: 1) professional, 2) state, 3) institutional, and 4) self-determined. [3]
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