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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 ...
series) is a product line of how-to and other reference books published by Dorling Kindersley (DK). The books in this series provide a basic understanding of a complex and popular topics. The term "idiot" is used as hyperbole, to reassure readers that the guides will be basic and comprehensible, even if the topics seem intimidating.
Dan Gookin is a computer book author who wrote the first ...For Dummies books including DOS for Dummies and PCs for Dummies, establishing the design and voice of the long-running series that followed, incorporating humor and jokes into a format for beginners on any subject. He also is a member of the Coeur d'Alene City Council.
The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA) standard. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing).
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
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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Notes on Nursing: What it is and What it is Not is a book first published by Florence Nightingale in 1859. [1] [2] [3] A 76-page volume with 3 page appendix published by Harrison of Pall Mall, it was intended to give hints on nursing to those entrusted with the health of others.
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