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  2. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    The significance of the CCC is a nursing terminology that completes the missing link needed to address nursing contribution to healthcare quality. Nursing care may be the most critical factor in a patient's treatment and recovery. [31] The partnership of nursing and technology is vital for designing nursing practice environments. [32]

  3. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    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 ...

  4. National Council Licensure Examination - Wikipedia

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

    English and French: Annual number of test takers: NCLEX-RN: 358,998 (in 2023) [1] NCLEX-PN: 65,679 (in 2023) [1] Prerequisites: Candidate must be a graduate of an approved nursing school. Fluency in English assumed. Fee: $200 USD or $360 CAD: Used by: State Boards of Nursing in United States and Board of Nursing in 10 Canadian provinces ...

  5. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    [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 ...

  6. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...

  7. Nursing - Wikipedia

    en.wikipedia.org/wiki/Nursing

    Nursing A nurse checks a patient's blood pressure. Occupation Activity sectors Nursing Description Competencies Caring for general and specialized well-being of patients Education required Qualifications in terms of statutory regulations according to national, state, or provincial legislation in each country Fields of employment Hospital Clinic Laboratory Research Education Home care Related ...

  8. 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 ...

  9. ICD-10 Procedure Coding System - Wikipedia

    en.wikipedia.org/wiki/ICD-10_Procedure_Coding_System

    The ICD-10 Procedure Coding System (ICD-10-PCS) is a US system of medical classification used for procedural coding.The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1995 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM.