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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. Nursing documentation is the principal clinical information source to meet legal ...
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.
Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence". [1] Nurses practice in many specialties with ...
There are multiple educational pathways to becoming a registered nurse. Education for an RN can include: a Bachelor’s degree in nursing (BSN), which typically takes 4 years. an Associate’s ...
This type of communication lets the patient ask questions and accept or deny treatment. In a healthcare setting, the process of informed consent includes: your ability to make a decision
In the media, hospital terms that describe a patient’s condition -- like critical, fair, serious, stable -- are vague by design. They give you just a general sense of how someone is doing, which ...
The patient's health record is a legal document that contains details regarding patient's care and progress. 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 they ...
ordering diagnostic tests such as lab work and X-rays. designing treatment plans. performing necessary medical treatments. teaching patients about medical conditions and treatments. Nurse ...