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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 ]
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.
SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. [1] ... P – Past Pertinent medical history; L – Last Oral Intake ...
As a form of knowledge management and knowledge organization, documentation can be provided on paper, online, or on digital or analog media, such as audio tape or CDs. Examples are user guides, white papers, online help, and quick-reference guides. Paper or hard-copy documentation has become less common.
The 2003 sixth edition changed the title to MLA Handbook for Writers of Research Papers. The seventh edition 's main changes from the sixth edition were "no longer recogniz[ing] a default medium and instead call[ing] for listing the medium of publication [whether Print or Web or CD] in every entry in the list of works cited", recommending ...
The shooting appeared random at first, but police eventually unspooled a strange plot involving Li's ex-wife and a bitter custody dispute over their son, Arik, who has severe disabilities stemming ...
Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care.
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