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  2. Omaha System - Wikipedia

    en.wikipedia.org/wiki/Omaha_System

    The American Nurses Association recognized the Omaha System as a standardized terminology to support nursing practice in 1992. In 2014, Minnesota became the first state to recommend that point-of-care terminologies recognized by the American Nurses Association be used in all electronic health records. The evidence underlying this decision was a ...

  3. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    A nursing care component is defined as a cluster of elements that represents a unique pattern of clinical care nursing practice; namely, Health Behavioral, Functional, Physiological, and Psychological. Nursing Diagnoses: A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs.

  4. Behavioral health outcomes management - Wikipedia

    en.wikipedia.org/wiki/Behavioral_health_outcomes...

    Behavioral health outcome management (BHOM) involves the use of behavioral health outcome measurement data to help guide and inform the treatment of each individual patient. Like blood pressure, cholesterol and other routine lab work that helps to guide and inform general medical practice, the use of routine measurement in behavioral health is ...

  5. Primary care behavioral health - Wikipedia

    en.wikipedia.org/wiki/Primary_Care_Behavioral_health

    The primary care behavioral health (PCBH) consultation model is a psychological approach to population-based clinical health care that is simultaneously co-located, collaborative, and integrated within the primary care clinic. The goal of PCBH is to improve and promote overall health within the general population.

  6. Subjective units of distress scale - Wikipedia

    en.wikipedia.org/wiki/Subjective_units_of...

    It has been used in cognitive-behavioral treatments for anxiety disorders (e.g. exposure practices and hierarchy) and for research purposes. There is no hard and fast rule by which a patient can self assign a SUDS rating to his or her disturbance or distress, hence the name subjective. Some guidelines are:

  7. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    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.

  8. Nursing Outcomes Classification - Wikipedia

    en.wikipedia.org/wiki/Nursing_Outcomes...

    The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association -recognized terminology, is ...

  9. Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Minimum_Data_Set

    MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. Participants in the assessment process are health care professionals and direct care staff such as registered nurses , licensed practical or vocational nurses (LPN/LVN), Therapists, Social Services ...