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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
"In the United States, certified nursing assistants typically work in a nursing home or hospital and perform everyday living tasks for the elderly, chronically sick, or rehabilitation patients who cannot care for themselves." [11] Many community colleges offer CNA training in one semester. Other educational programs offer accelerated programs.
The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1] [2] [3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics. The diagnosis phase was ...
The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.
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.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
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An objective structured clinical examination (OSCE) is an approach to the assessment of clinical competence in which the components are assessed in a planned or structured way with attention being paid to the objectivity of the examination which is basically an organization framework consisting of multiple stations around which students rotate and at which students perform and are assessed on ...
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