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A specific type of change-of-shift report is Nursing Bedside Shift Report in which the off going nurse provides change-of-shift report to the on coming nurse at the patient's bedside. [ 1 ] [ 6 ] [ 7 ] Since 2013, giving report at the patient bedside has been recommend by the Agency for Healthcare Research and Quality (AHRQ) to improve patient ...
The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well. [11] Cyclic and dynamic
The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting.
A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
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 directives linked to the problems. It shows the evolution of the clinical profile of a patient.
The chief nurse is a registered nurse who supervises the care of all the patients at a health care facility. The chief nurse is the senior nursing management position in an organization and often holds executive titles like chief nursing officer (CNO), chief nurse executive, or vice-president of nursing. They typically report to the CEO or COO.
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
A problem statement is a description of an issue to be addressed, or a condition to be improved upon. It identifies the gap between the current problem and goal. The first condition of solving a problem is understanding the problem, which can be done by way of a problem statement.