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Health assessment has been separated by authors from physical assessment to include the focus on health occurring on a continuum as a fundamental teaching. [8] In the healthcare industry it is understood health occurs on a continuum, so the term used is assessment but may be preference by the speciality's focus such as nursing, physical therapy, etc.
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.
During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5] Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6]
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 original purpose of the model was to be an assessment used throughout the patient's care, but it has become the norm in UK nursing to use it only as a checklist on admission. It is often used to assess how a patient's life has changed due to illness or admission to hospital rather than as a way of planning for increased independence and ...
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
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.
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 ...