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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969), [2] that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic ...
An example of how the 2D Fourier transform can be used to remove unwanted information from an X-ray scan. The Faculty of Clinical Informatics has identified six high level domains of core competency for clinical informaticians: [7] Health and Wellbeing in Practice; Information Technologies and Systems; Working with Data and Analytical Methods
Case 3: The nurses in an ICU make daily decisions about allocation of nursing resources and bed according to the principles of justice. Case 4: A nurse caring for a terminally ill patient faces a conflict between fidelity to her commitment to relieve suffering and the promise made to the patient's family.
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
The theory of human caring, first developed by Watson in 1979, is patient care that involves a more holistic treatment for patients. As opposed to just using science to care for and heal patients, at the center of the theory of human caring is the idea that being more attentive and conscious during patient interactions allows for more effective and continuous care with a deeper personal ...
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 ...