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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 ...
To ensure that nursing homes meet the necessary legal standards, the authorities conduct inspections of all nursing home facilities; as often as quarterly. Surveyors conduct on-site surveys of certified nursing homes on average every 12 months to assure basic levels of quality and safety for beneficiaries.
The Clinical Care Classification (CCC), previously the Home Health Care Classification (HHCC), was originally created to document nursing care in home health and ambulatory care settings. [2] Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care.
Nursing home residents' rights are the legal and moral rights of the residents of a nursing home. [1] Legislation exists in various jurisdictions to protect such rights. An early example of a statute protecting such rights is Florida statute 400.022, enacted in 1980, and commonly known as the Residents' Rights Act.
Spry said a Vitas nurse persuaded her that hospice was the correct choice for her mother. The nurse touted the at-home care and help with other chores that had grown difficult, such as bathing her mother, Spry said. Spry signed the admission forms, even though she did not have the legal right to do so.
Nursing homes may also be referred to as care homes, skilled nursing facilities (SNF) or long-term care facilities. Often, these terms have slightly different meanings to indicate whether the institutions are public or private, and whether they provide mostly assisted living , or nursing care and emergency medical care .
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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]