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This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home and SNF staff identify health problems. Resource Utilization Groups (RUG) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated.
Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6] The nursing documents may contain a number of assessment forms. In an assessment form, a licensed Registered Nurse records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure ...
The Nursing Minimum Data Set (NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations ...
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well. [11] Cyclic and dynamic
Forms processing is a process by which one can capture information entered into data fields and convert it into an electronic format. This can be done manually or automatically, but the general process is that hard copy data is filled out by humans and then "captured" from their respective fields and entered into a database or other electronic format.
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...