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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]
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.
A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [ 1 ] [ 2 ] [ 3 ] Essential parts of a case presentation include:
In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases.
Examples include—ORRESU, --ORNRHI, and—ORNRLO, all of which are variable qualifiers of—ORRES, and—DOSU and—DOSFRM, all of which are variable qualifiers of—DOSE. For example, in the observation, 'Subject 101 had mild nausea starting on Study Day 6,' the Topic variable value is the term for the adverse event, 'NAUSEA'.
A case study is an in-depth, detailed examination of a particular case (or cases) within a real-world context. [1] [2] For example, case studies in medicine may focus on an individual patient or ailment; case studies in business might cover a particular firm's strategy or a broader market; similarly, case studies in politics can range from a narrow happening over time like the operations of a ...
Case series have a descriptive study design; unlike studies that employ an analytic design (e.g. cohort studies, case-control studies or randomized controlled trials), case series do not, in themselves, involve hypothesis testing to look for evidence of cause and effect (though case-only analyses are sometimes performed in genetic epidemiology ...
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