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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving ...

  3. Merck Manual of Diagnosis and Therapy - Wikipedia

    en.wikipedia.org/wiki/Merck_Manual_of_Diagnosis...

    The first edition of The Merck Manual was published in 1899 by Merck & Co., Inc. for physicians and pharmacists and was titled Merck's Manual of the Materia Medica. [6] [7] The 192 page book which sold for US $1.00, was divided into three sections, Part I ("Materia Medica") was an alphabetical listing of all known compounds thought to be of therapeutic value with uses and doses; Part II ...

  4. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.

  5. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...

  6. Point of care - Wikipedia

    en.wikipedia.org/wiki/Point_of_care

    Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]

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  8. Notes on Nursing - Wikipedia

    en.wikipedia.org/wiki/Notes_on_Nursing

    Notes on Nursing: What it is and What it is Not is a book first published by Florence Nightingale in 1859. [ 1 ] [ 2 ] [ 3 ] A 76-page volume with 3 page appendix published by Harrison of Pall Mall, it was intended to give hints on nursing to those entrusted with the health of others.

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