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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 ...
Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are ...
A home health aide (HHA) provides in-home care for patients who need assistance with daily living beyond what family or friends can provide. Patients include those who have a physical or mental disability, are recovering from an injury or surgery, have a chronic illness, or are advanced in age.
OpenNotes is a research initiative and international movement located at Beth Israel Deaconess Medical Center (affiliated with Harvard Medical School), that focuses on making health care more open and transparent by encouraging doctors, nurses, therapists, and other health care professionals to share clinical visit notes with patients, facilitating patients' legal right to access to their own ...
A caregiver, carer or support worker is a paid or unpaid person who helps an individual with activities of daily living. Caregivers who are members of a care recipient's family or social network, and who may have no specific professional training, are often described as informal caregivers.
Open-ended questions are those that cannot be answered with a simple "yes" or "no" response. If the person is unable to respond, then family or caregivers will be given the opportunity to answer the questions. [3] The typical nursing assessment in the clinical setting will be the collection of data about the following:
However, for patients for whom rolling to the side is contraindicated, such as those recovering from hip replacement surgery, the process is modified. These patients are assisted into a sitting position while the caregiver makes the top half of the bed. Once completed, the patient is then helped to lie back while the bottom half of the bed is made.
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