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Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
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.
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.
Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery.
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.
Original file (1,275 × 1,650 pixels, file size: 1.25 MB, MIME type: application/pdf, 4 pages) This is a file from the Wikimedia Commons . Information from its description page there is shown below.
The efficacy of EWSs in improving patient outcomes is also reliant on a number of personal and structural factors. For example, a lack of clinician knowledge of the EWS, incomplete or incorrect vital sign measurement, and the influence of power between nursing and medical staff hinder detection of clinical deterioration. [3]
Vital Sign Alert System is an alert system designed by nurses at Sentara Norfolk General Hospital in Norfolk, Virginia. [when?] The alert system, which replaced an ineffective early warning scoring (EWS) system, is a unique creation designed specifically to enhance patient monitoring on medical–surgical and step-down nursing units without increasing the nurse's workload.