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The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1][2] Documenting patient encounters in the medical record is an integral part of practice workflow ...
The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. 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 ...
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...
The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan. The NIC provides a four level hierarchy whose first two levels consists of a list of 433 different ...
Roy's goal for nursing is "the promotion of adaptation in each of the four modes, thereby contributing to the person's health, quality of life and dying with dignity". [1] These four modes are physiological, self-concept, role function and interdependence. Roy employs a six-step nursing process: assessment of behaviour; assessment of stimuli ...
Nursing Interventions: A nursing intervention is defined as a single nursing action – treatment, procedure or activity – designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable. [12] Patient services are usually initiated as medical orders by a referring physician and reviewed by the admitting ...
Evidence-based nursing (EBN) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic. This approach is using evidence-based practice (EBP) as a foundation. EBN implements the most up to date methods of providing ...
The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1] [2] [3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics. The diagnosis phase was ...
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