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  2. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals [clarification needed] and EKG's [clarification needed] may be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017 [clarification needed]) It differs from a medical diagnosis ...

  3. Gordon's functional health patterns - Wikipedia

    en.wikipedia.org/wiki/Gordon's_functional_health...

    Cognitive-perceptual-assessment of neurological function is done to assess, check the person's ability to comprehend information; Self perception/self concept; Role relationship—This pattern should only be used if it is appropriate for the patient's age and specific situation. Sexual reproductivity; Coping-stress tolerance; Value-Belief Pattern

  4. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    For example, Wang et al. [16] that although the electronic nursing assessment form contained more documented assessment forms, which covered a wider range of resident care needs, they did not perform better than the previous [null paper-based assessment forms according to] the quality criteria of [null completeness] and timeliness. Therefore ...

  5. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.

  6. Template:Medical records and physical exam - Wikipedia

    en.wikipedia.org/wiki/Template:Medical_records...

    To change this template's initial visibility, the |state= parameter may be used: {{Medical records and physical exam | state = collapsed}} will show the template collapsed, i.e. hidden apart from its title bar. {{Medical records and physical exam | state = expanded}} will show the template expanded, i.e. fully visible.

  7. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    see Physical examination#Example: see Physical examination#Example: labs and diagnostics studies "none" May cover studies performed at an outside hospital, during prior admissions, or in the ER before the current admission. assessment and plan (A&P) "Pt is a 30 yo female..." Assessment and plan are very closely related, and are often reported ...