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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. The use of the CCC has expanded into other settings, and it is claimed to be appropriate for multidisciplinary documentation. [3]
[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
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.
An example of a health promotion diagnosis is: Readiness for enhanced nutrition. Syndrome diagnosis A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions. An example of a syndrome diagnosis is: Relocation stress syndrome. [11]
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Questions on the NCLEX exam are of three different types or levels: Level 1, Level 2, and Level 3. Level 1 questions are the most basic questions and make up less than 10 percent of the total questions. Level 1 questions test the individual's knowledge and understanding. These questions require the individual to recall specific facts and ...