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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 .
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 ...
An executive summary (or management summary, sometimes also called speed read) is a short document or section of a document produced for business purposes. It summarizes a longer report or proposal or a group of related reports in such a way that readers can rapidly become acquainted with a large body of material without having to read it all.
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.
A director of nursing (DON) is a registered nurse who supervises the care of all the patients at a health care facility. [1] The director of nursing has special training beyond the training of a staff nurse for the position that pertains to health care management, and in some places, a director of nursing must hold a special license in order to be employed in that capacity.
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The situation, task, action, result (STAR) format is a technique [1] used by interviewers to gather all the relevant information about a specific capability that the job requires.
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