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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 .
Above: Florence Nightingale, the founder of modern nursing. A registered nurse (RN) is a nurse who has graduated or successfully passed a nursing program from a recognized nursing school and met the requirements outlined by a country, state, province or similar government-authorized licensing body to obtain a nursing license.
Nursing credentials and certifications are the various credentials and certifications that a person must have to practice nursing legally. Nurses' postnominal letters (abbreviations listed after the name) reflect their credentials—that is, their achievements in nursing education , licensure , certification , and fellowship .
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
These documents must be capable of including data elements known as the "Common MU Data Set" that include: Patient name, sex, date of birth, race, ethnicity, preferred language, smoking status, problems, medications, medication allergies, laboratory tests, laboratory values/results, vital signs, care plan fields including goals and instructions ...
Patricia Sawyer Benner is a nursing theorist, academic and author. She is known for one of her books, From Novice to Expert: Excellence and Power in Clinical Nursing Practice (1984). Benner described the stages of learning and skill acquisition across the careers of nurses, applying the Dreyfus model of skill acquisition to nursing
An advanced practice nurse (APN) is a nurse with post-graduate education and training in nursing. Nurses practicing at this level may work in either a specialist or generalist capacity. APNs are prepared with advanced didactic and clinical education, knowledge, skills, and scope of practice in nursing.
MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online) is a bibliographic database of life sciences and biomedical information. It includes bibliographic information for articles from academic journals covering medicine, nursing, pharmacy, dentistry, veterinary medicine, and health care.