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  2. Braden Scale for Predicting Pressure Ulcer Risk - Wikipedia

    en.wikipedia.org/wiki/Braden_Scale_for...

    Friction and shear looks at the amount of assistance a client needs to move and the degree of sliding on beds or chairs that they experience. This category is assessed because the sliding motion can cause shear which means the skin and bone are moving in opposite directions causing breakdown of cell membranes and capillaries. Moisture enhances ...

  3. 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.

  4. 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 ...

  5. List of medical abbreviations: P - Wikipedia

    en.wikipedia.org/wiki/List_of_medical...

    Pink, warm, and dry (skin assessment) PWP: pulmonary wedge pressure: Px px: physical examination prognosis patient: P-Y: Pack-year (years of smoking multiplied by average number of packs, or fraction thereof, per day) PZA: pyrazinamide

  6. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note, where the note is organized into Subjective, Objective, Assessment, and Plan sections.

  7. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    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.