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Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process .
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
The three most common systems are the FDI World Dental Federation notation (ISO 3950), the Universal Numbering System, and the Palmer notation. The FDI notation is used worldwide, and the Universal is used widely in the United States. The FDI notation can be easily adapted to computerized charting. Another system is used by paleoanthropologists.
The assessment begins with a dental-health questionnaire, including questions about toothache, hoarseness, dysphagia (difficulty swallowing), altered taste or a frequent sore throat, current and previous tobacco use and alcohol consumption and any sores, lesions or bleeding of the gums.
Universal numbering system. This is a dental practitioner view, so tooth number 1, the rear upper tooth on the patient's right, appears on the left of the chart. The Universal Numbering System, sometimes called the "American System", is a dental notation system commonly used in the United States. [1] [2]
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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.