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A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. [8] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. [8]
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] The Clinical Care Classification (CCC), previously the Home Health Care Classification (HHCC), was originally created to document nursing care in home health and ambulatory care settings ...
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 ...
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 ]
Plates vi & vii of the Edwin Smith Papyrus (around the 17th century BC), among the earliest medical guidelines. A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare.
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.
NANDA developed a nursing classification to organize nursing diagnoses into different categories. Although the taxonomy was revised to accommodate new diagnoses, in 1994 it became apparent that an overhaul was needed. In 2002 Taxonomy II, which was a revised version of Gordon's functional health patterns (Gordon, 1994), was released.
The Philippine Board of Nursing is an administrative body under the Professional Regulation Commission that regulates the practice of nursing in the Philippines. Its three primary purposes are: To provide regulatory standards in the practice of Nursing by implementing the Nurse Practice Act and by lobbying to Congress any proposed amendment to ...