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  2. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    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.

  3. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    The nursing documents may contain a number of assessment forms. In an assessment form, a licensed Registered Nurse records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing assessment determine the accuracy of care planning in the nursing ...

  4. Gordon's functional health patterns - Wikipedia

    en.wikipedia.org/wiki/Gordon's_functional_health...

    Cognitive-perceptual-assessment of neurological function is done to assess, check the person's ability to comprehend information; Self perception/self concept; Role relationship—This pattern should only be used if it is appropriate for the patient's age and specific situation. Sexual reproductivity; Coping-stress tolerance; Value-Belief Pattern

  5. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.

  6. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

  7. Nursing process - Wikipedia

    en.wikipedia.org/wiki/Nursing_process

    The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1] [2] [3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics. The diagnosis phase was ...

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  9. National Council Licensure Examination - Wikipedia

    en.wikipedia.org/wiki/National_Council_Licensure...

    The National Council Licensure Examination (NCLEX) is a nationwide examination for the licensing of nurses in the United States, Canada, and Australia since 1982, 2015, and 2020, respectively. [2] [3] There are two types: the NCLEX-RN and the NCLEX-PN. After graduating from a school of nursing, one takes the NCLEX exam to receive a nursing license.

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