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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8]

  3. Gordon's functional health patterns - Wikipedia

    en.wikipedia.org/wiki/Gordon's_functional_health...

    Activity exercise-whether one is able to do daily activities normally without any problem, self care activities; Sleep rest-do they have hypersomnia, insomnia, do they have normal sleeping patterns; Cognitive-perceptual-assessment of neurological function is done to assess, check the person's ability to comprehend information

  4. Omaha System - Wikipedia

    en.wikipedia.org/wiki/Omaha_System

    The evidence underlying this decision was a survey that showed that the Omaha System was used in 96.5% of Minnesota counties. The Omaha System became a member of the Alliance for Nursing Informatics in 2009. It is a reliable nursing documentation tool for outcome and quality of care measurement for clients with mental illness. [11]

  5. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    A nursing care component is defined as a cluster of elements that represents a unique pattern of clinical care nursing practice; namely, Health Behavioral, Functional, Physiological, and Psychological. Nursing Diagnoses: A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs.

  6. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.

  7. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    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 ...

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    mail.aol.com

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  9. Primary nursing - Wikipedia

    en.wikipedia.org/wiki/Primary_nursing

    Primary nursing is a system of nursing care delivery that emphasizes continuity of care and responsibility acceptance by having one registered nurse (RN), often teamed with a licensed practical nurse (LPN) and/or nursing assistant (NA), who together provide complete care for a group of patients throughout their stay in a hospital unit or department. [1]