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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]
SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication.This communication model has gained popularity in healthcare settings, especially amongst professions such as physicians and nurses.
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
Preventive action is any proactive method used to determine potential discrepancies before they occur and to ensure that they do not happen (thereby including, for example, preventive maintenance, management review or other common forms of risk avoidance). Corrective and preventive actions include stages for investigation, action, review, and ...
The ABC (abstract, body, and conclusion) format can be used when writing a first draft of some document types. The abstract describes the subject so that the reader knows what the document covers. The body is the majority of the document and covers topics in depth. Lastly, the conclusion section restates the document's main topics.
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The published document should be in a format that is not easily altered without a specific knowledge or tools, and yet it is read-only or portable. [17] Hard copy reproduction: Document/image reproduction is often necessary within a document management system, and its supported output devices and reproduction capabilities should be considered. [18]
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