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Nursing care plans provide continuity of care, safety, quality care and compliance. 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 ...
A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care. Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
Alfresco, an example of on-premises document management software An Example of on-premises software (MediaWiki). On-premises software (abbreviated to on-prem, and often written as "on-premise") [1] is installed and runs on computers on the premises of the person or organization using the software, rather than at a remote facility such as a server farm or cloud.
The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association -recognized terminology, is ...
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
Continuity of Care Document; Fast Healthcare Interoperability Resources (FHIR) is a Health Level 7 interoperability specification that defines JSON and XML data formats and a RESTful API. [64] [65] It is available under the CC0 license. [66]
The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan.