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Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions.
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 ...
The systematic review of nursing documentation audit studies in different settings [19] identified the following relevant quality characteristics of nursing documentation: Quality of documentation structure and format: relates to constructive features and physical presentation of records such as quantity, completeness, legibility, read- ability ...
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnosis. In 2002, NANDA became NANDA ...
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.
It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses.
Mosby's Dictionary of Medicine, Nursing & Health Professions is a dictionary of health-related topics. The 8th edition, published in 2009, contains 2,240 pages and 2,400 colour illustrations. The 8th edition, published in 2009, contains 2,240 pages and 2,400 colour illustrations.
The book contains many guidelines and recommendations for the prevention of chronic diseases and micronutrient deficiencies such as beriberi, xerophthalmia, and goitre. [7] Wushi'er Bingfang (c. 200 BCE) Shennong Ben Cao Jing (c. 200 CE) Shanghan Lun (c. 220 CE) Liu Juanzi Guiyi Fang (C. 499 CE) Compendium of Materia Medica (c. 1578 CE)