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A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process .
"In the United States, certified nursing assistants typically work in a nursing home or hospital and perform everyday living tasks for the elderly, chronically sick, or rehabilitation patients who cannot care for themselves." [11] Many community colleges offer CNA training in one semester. Other educational programs offer accelerated programs.
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]
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.
Registered practical nurse is equivalent to licensed practical nurse in Canada and is a region specific title. [ 36 ] Licensed Practical Nurse (LPN), in the other Canadian provinces ( British Columbia , Alberta , Saskatchewan , Manitoba , Prince Edward Island , Nova Scotia , New Brunswick , Newfoundland and Labrador and the territories).
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[7] [8] In India, Community Health Officer or Nurse practitioner, Physician Associate/Assistant are other names for mid-level practitioner. [9] Apart from doctor and nurses there was a list of Healthcare providers as recently NCAHP,Ministry of Health and Family Welfare published Guideline in Ayusman Bharat digital Health Mission control of ...