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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. Nursing documentation is the principal clinical information source to meet legal ...
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnosis. In 2002, NANDA became NANDA ...
The first edition of standards was released in 2006 and after that, the standards have been revised every 3 years. Currently the 5th edition of NABH standards, released in August 2020 is in use. The organization has to go for re-assessment after every 2 years. After every re-assessment, the renewal certificate is obtained by the hospital.
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.
The work of the HCPC and other health professions regulators in the UK (the General Medical Council, Nursing and Midwifery Council, General Dental Council, etc.) is overseen by the Professional Standards Authority. On 2 December 2019, the regulation of social workers in England was transferred to a new body, Social Work England. [10]
Standards-based audit – A cycle which involves defining standards, collecting data to measure current practice against those standards, and implementing any changes deemed necessary. Adverse occurrence screening and critical incident monitoring – This is often used to peer review cases which have caused concern or from which there was an ...