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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]
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]
The nursing process is goal-oriented method of caring that provides a framework to nursing care. It involves seven major steps: A; Assess (what data is collected?) D; Diagnose (what is the problem?) O; Outcome Identification - (Was originally a part of the Planning phase, but has recently been added as a new step in the complete process). P
Donabedian developed his quality of care framework to be flexible enough for application in diverse healthcare settings and among various levels within a delivery system. At its most basic level, the framework can be used to modify structures and processes within a healthcare delivery unit, such as a small group practice or ambulatory care ...
Point of care medical information summaries are defined as "web-based medical compendia specifically designed to deliver predigested, rapidly accessible, comprehensive, periodically updated, and evidence-based information" to healthcare providers.
Point-of-care testing (POCT), also called near-patient testing or bedside testing, is defined as medical diagnostic testing at or near the point of care—that is, at ...
Nursing care plans provide continuity of care, safety, quality care and compliance. A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid . The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing ...
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.