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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    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. Nursing documentation is the principal clinical information source to meet legal ...

  3. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future.

  4. Nursing process - Wikipedia

    en.wikipedia.org/wiki/Nursing_process

    The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well. [11] Cyclic and dynamic

  5. Journal of Documentation - Wikipedia

    en.wikipedia.org/wiki/Journal_of_Documentation

    The Journal of Documentation is a double-blind peer-reviewed academic journal covering theories, concepts, models, frameworks, and philosophies in information science. The journal publishes scholarly articles, research reports, and critical reviews. The first editor was Theodore Besterman. [2]

  6. Time and motion study - Wikipedia

    en.wikipedia.org/wiki/Time_and_motion_study

    A health care time and motion study is used to research and track the efficiency and quality of health care workers. [31] In the case of nurses, numerous programs have been initiated to increase the percent of a shift nurses spend providing direct care to patients. Prior to interventions nurses were found to spend ~20% of their time doing ...

  7. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

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  9. Donabedian model - Wikipedia

    en.wikipedia.org/wiki/Donabedian_model

    The Donabedian model is a conceptual model that provides a framework for examining health services and evaluating quality of health care. [1] According to the model, information about quality of care can be drawn from three categories: "structure", "process", and "outcomes". [2]