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Evidence-based nursing (EBN) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic.
An objective structured clinical examination (OSCE) is an approach to the assessment of clinical competence in which the components are assessed in a planned or structured way with attention being paid to the objectivity of the examination which is basically an organization framework consisting of multiple stations around which students rotate and at which students perform and are assessed on ...
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ...[It] means integrating individual clinical expertise with the best available external clinical evidence from systematic research."
That acronym can be pronounced as 'soap' but reminds us that we will be formulating with clinical hypotheses instead of plugging in a simple diagnostic label. Kettenbach, Ginge; Schlomer, Sarah L. (2016) [1990]. Writing patient/client notes: ensuring accuracy in documentation (5th ed.). F. A. Davis Company. ISBN 9780803638204. OCLC 934020211.
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.