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An admission form is a fundamental record in nursing documentation. It documents a client's status, reasons why the client is being admitted, and the initial instructions for that client's care. [3] The form is completed by a nurse when a client is admitted to a health care facility.
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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 ...
A specific type of change-of-shift report is Nursing Bedside Shift Report in which the off going nurse provides change-of-shift report to the on coming nurse at the patient's bedside. [ 1 ] [ 6 ] [ 7 ] Since 2013, giving report at the patient bedside has been recommend by the Agency for Healthcare Research and Quality (AHRQ) to improve patient ...
The patient's health record is a legal document that contains details regarding patient's care and progress. [3] The types of information captured during the clinical point of care documentation include the actions taken by clinical staff including physicians and nurses, and the patient's healthcare needs, goals, diagnosis and the type of care ...
The chief nurse is a registered nurse who supervises the care of all the patients at a health care facility. The chief nurse is the senior nursing management position in an organization and often holds executive titles like chief nursing officer (CNO), chief nurse executive, or vice-president of nursing. They typically report to the CEO or COO.