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Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
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.
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
Notes on Nursing: What it is and What it is Not is a book first published by Florence Nightingale in 1859. [1] [2] [3] A 76-page volume with 3 page appendix published by Harrison of Pall Mall, it was intended to give hints on nursing to those entrusted with the health of others.
The Nightingale Pledge is a statement of the ethics and principles of the nursing profession in the United States, and it is not used outside the US. It included a vow to "abstain from whatever is deleterious and mischievous" and to "zealously seek to nurse those who are ill wherever they may be and whenever they are in need."
A director of nursing (DON) is a registered nurse who supervises the care of all the patients at a health care facility. [1] The director of nursing has special training beyond the training of a staff nurse for the position that pertains to health care management, and in some places, a director of nursing must hold a special license in order to be employed in that capacity.