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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. Nursing documentation is the principal clinical information source to meet legal ...
Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be required anywhere from several times an hour to several times a day.
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]
The Continuity of Care Document (CCD) specification is an XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange. [ 1 ]
The model is one of the most commonly used frameworks that have shaped evidence-based nursing. [ 2 ] The model was developed by Dr. Kathleen Stevens at the Academic Center for Evidence-Based Practice located at the University of Texas Health Science Center at San Antonio . [ 3 ]
SNOMED started in 1965 as a Systematized Nomenclature of Pathology (SNOP) and was further developed into a logic-based health care terminology. [6] [7]SNOMED CT was created in 1999 by the merger, expansion and restructuring of two large-scale terminologies: SNOMED Reference Terminology (SNOMED RT), developed by the College of American Pathologists (CAP); and the Clinical Terms Version 3 (CTV3 ...
A handcuffed inmate whose fatal beating by correctional officers last year sparked outrage died by homicide, according to findings of an autopsy report a lawyer for the man's family shared Wednesday.
Nursing theories frame, explain or define the practice of nursing. Roy's model sees the individual as a set of interrelated systems (biological, psychological and social). The individual strives to maintain a balance between these systems and the outside world, but there is no absolute level of balance.
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