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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 ]
Quality tools include: [1] Medical guidelines, including checklists [2] (items rated as yes/no/not applicable); Templates [3] for goal setting or structured communication (a more open format than checklists, templates provide the opportunity to add free text responses with items as prompts)
The CCC is a nursing terminology specifically developed for computerization: e.g. electronic healthcare information systems (EHR), computer-based patient records (CPR), and Clinical Information Systems (CIS), from research which collected live patient care data. The CCC System describes the six steps of the nursing process: Assessment; Diagnosis
The result was a four-part, front-page series that ran from October 23 to 26, 2005, entitled Critical Care: The making of an ICU nurse. [10] The added psychological stress of nursing in critical care units has been well-documented, and it has been argued the stress experienced in ICU areas are unique in the profession. [11]
Intensive care medicine, usually called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. [1] It includes providing life support, invasive monitoring techniques, resuscitation, and end-of-life care. [2]
In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]
A notable marker of primary research is the inclusion of a "methods" section, where the authors describe how the data was generated. Common examples of secondary research include textbooks, encyclopedias, news articles, review articles, and meta analyses. [2] [3] When conducting secondary research, authors may draw data from published academic ...
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.