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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 ...
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. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
The nursing process uses clinical judgement to strike a balance of epistemology between personal interpretation and research evidence in which critical thinking may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing. [5] Nursing knowledge has embraced pluralism since the 1970s. [6]
It makes the process of nursing assessment visible through what is presented in the documentation content. [4] During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5]
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.
Verification is intended to check that a product, service, or system meets a set of design specifications. [6] [7] In the development phase, verification procedures involve performing special tests to model or simulate a portion, or the entirety, of a product, service, or system, then performing a review or analysis of the modeling results.
Identification and demographics: name, age, height, weight. The "chief complaint (CC)" – the major health problem or concern, and its time course (e.g. chest pain for past 4 hours). History of the present illness (HPI) – details about the complaints, enumerated in the CC (also often called history of presenting complaint or HPC).
Compliance refers to the human-subject response to a proposed experimental treatment condition. Similar to the ATE, the LATE is calculated but does not include non-compliant parties. If the goal is to evaluate the effect of a treatment in ideal, compliant subjects, the LATE value will give a more precise estimate.