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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
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.
The Patient-Reported Outcomes Measurement Information System [1] (PROMIS) provides clinicians and researchers access to reliable, valid, and flexible measures of health status that assess physical, mental, and social well–being from the patient perspective. PROMIS measures are standardized, allowing for assessment of many patient-reported ...
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 .
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
The discipline of HTA was first developed in the U.S. Office of Technology Assessment, which published its first report in 1976. [9] The growth of HTA internationally can be seen in the expanding membership of the International Network of Agencies for Health Technology Assessment (INAHTA), a non-profit umbrella organization established in 1993. [10]
Phil Lucas, a 32-year-old Suboxone patient, said he tried local NA meetings but no longer attends. “They acted like I was still a heroin addict basically,” he said, adding that people at the meetings kept asking him when he was going to get sober. Diana Sholler, 43, another Suboxone patient in Northern Kentucky, attends local AA meetings.
A major challenge in the shift reports is communication issues between outgoing and incoming nurses, which are the leading cause of reduced service safety and patient dissatisfaction. The review identified several key challenges, including poor coordination, time management, non-use of checklists, and inadequate management.