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Standard 8 of the National Safety and Quality Health Service (NSQHS) Standards is Recognising and Responding to Acute Deterioration, which centres on the early detection of deterioration and escalation of care. Action 8.4 of the standard explicitly states that health services are to "graphically document and track changes in agreed observations ...
The CCC System was one of the standards in the first set of 55 national standards approved for use in the EHR, by the Department of Health and Human Services (AHIC, 2006) and the only national nursing terminology standard. In 2020, HCA Healthcare became the new custodian of Dr. Virginia Saba's Clinical Care Classification (CCC) System.
The National Safety and Quality Health Service Standards (NSQHS Standards) are Australia's principal health care standards, and apply to all health services including inpatient, outpatient, and community care. [5] There are 8 standards: Clinical governance; Partnering with consumers; Preventing and controlling infections; Medication safety
A study by the National Client Safety Agency (NPSA) [17] found that poor standards of documentation were a contributory factor in the failure to detect clients who were clinically deteriorating. Nurses are responsible for maintaining accurate records of the care they provide and are accountable if information is incomplete and inaccurate. [ 18 ]
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 ...
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 ...
Unlike its counterpart, the Occupational Safety and Health Administration, NIOSH's authority under the Occupational Safety and Health Act [29 CFR § 671] is to "develop recommendations for health and safety standards", to "develop information on safe levels of exposure to toxic materials and harmful physical agents and substances", and to "conduct research on new safety and health problems".
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.