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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.
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.
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.
S.M.A.R.T. (or SMART) is an acronym used as a mnemonic device to establish criteria for effective goal-setting and objective development. This framework is commonly applied in various fields, including project management, employee performance management, and personal development.
Objectives and key results (OKR, alternatively OKRs) is a goal-setting framework used by individuals, teams, and organizations to define measurable goals and track their outcomes. The development of OKR is generally attributed to Andrew Grove who introduced the approach to Intel in the 1970s [ 1 ] and documented the framework in his 1983 book ...
Management by objectives (MBO), also known as management by planning (MBP), was first popularized by Peter Drucker in his 1954 book The Practice of Management. [1] Management by objectives is the process of defining specific objectives within an organization that management can convey to organization members, then deciding how to achieve each objective in sequence.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
An objective structured clinical examination (OSCE) is an approach to the assessment of clinical competence in which the components are assessed in a planned or structured way with attention being paid to the objectivity of the examination which is basically an organization framework consisting of multiple stations around which students rotate ...