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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.
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
However, for patients for whom rolling to the side is contraindicated, such as those recovering from hip replacement surgery, the process is modified. These patients are assisted into a sitting position while the caregiver makes the top half of the bed. Once completed, the patient is then helped to lie back while the bottom half of the bed is made.
Psychomotor agitation is a symptom in various disorders and health conditions. It is characterized by unintentional and purposeless motions and restlessness, often but not always accompanied by emotional distress and is always an indicative for admission.
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These nursing actions can take place at any point in the patient's recovery. For example, the ICU nurse may put in a long-term disability referral for a patient who is likely to survive ICU with new physical deficits. Furthermore, a home care nurse could suggest a peer-support group for a PICS patient with new social dysfunctions.