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Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions.
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 ...
The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and ...
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.
Narrative therapy embodies a strong appreciation for the creation and use of documents, as when a person and a counsellor co-author "A Graduation from the Blues Certificate", for example. [25] In some instances, case notes are created collaboratively with clients to provide documentation as well as markers of progress.
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The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) is used to diagnose dissociative disorders, especially in research settings.It was originally designed for the DSM-III-R but early access to DSM-IV criteria for dissociative disorders allowed them to be incorporated into the SCID-D. [7]
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