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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving ...

  3. Clinical Care Classification System - Wikipedia

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

    The CCC is a nursing terminology specifically developed for computerization: e.g. electronic healthcare information systems (EHR), computer-based patient records (CPR), and Clinical Information Systems (CIS), from research which collected live patient care data. The CCC System describes the six steps of the nursing process: Assessment; Diagnosis

  4. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Physicians are generally required to generate at least one progress note for each patient encounter. 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 ...

  5. Glossary of clinical research - Wikipedia

    en.wikipedia.org/wiki/Glossary_of_clinical_research

    A type of research study that tests how well new medical approaches work in people. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease. Also called a clinical trial. (NCI) A clinical trial is a research study to answer specific questions about vaccines or new therapies or new ways of using known ...

  6. APA style - Wikipedia

    en.wikipedia.org/wiki/APA_style

    APA style (also known as APA format) is a writing style and format for academic documents such as scholarly journal articles and books. It is commonly used for citing sources within the field of behavioral and social sciences, including sociology, education, nursing, criminal justice, anthropology, and psychology.

  7. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    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 directives linked to the problems. It shows the evolution of the clinical profile of a patient.

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  9. Medical Subject Headings - Wikipedia

    en.wikipedia.org/wiki/Medical_Subject_Headings

    The main ones are the "headings" (also known as MeSH headings or descriptors [2]), which describe the subject of each article (e.g., "Body Weight", "Brain Edema" or "Critical Care Nursing"). Most of these are accompanied by a short description or definition, links to related descriptors, and a list of synonyms or very similar terms (known as ...