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A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [ 1 ] [ 2 ] [ 3 ] Essential parts of a case presentation include:
APA style (also known as APA format) is a writing style and format for academic documents such as scholarly journal articles and books. It is commonly used for citing sources within the field of behavioral and social sciences, including sociology, education, nursing, criminal justice, anthropology, and psychology.
Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving ...
In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases.
A case study is an in-depth, detailed examination of a particular case (or cases) within a real-world context. [1] [2] For example, case studies in medicine may focus on an individual patient or ailment; case studies in business might cover a particular firm's strategy or a broader market; similarly, case studies in politics can range from a narrow happening over time like the operations of a ...
The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their ...
Any pertinent information pertaining to the sample must be included for the reader to judge the study as worthy. In addition, the current evidence-based practice (EBP) movement in healthcare emphasizes that clinical decision making should be based on the "best evidence" available, preferably the findings of randomized clinical trials.
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.