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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    A written record of the history, treatment, care, and response of the client while under the care of a health care provider. A guide for reimbursement of care costs. Evidence of care in a court of law. A legal record that can be used as evidence of events that occurred or treatments given. Show the use of the nursing process.

  3. Roper–Logan–Tierney model of nursing - Wikipedia

    en.wikipedia.org/wiki/Roper–Logan–Tierney...

    The Roper, Logan and Tierney model of nursing (originally published in 1980, and subsequently revised in 1985, 1990, 1998 and the latest edition in 2000) is a model of nursing care based on activities of living (ALs). It is extremely prevalent in the United Kingdom, particularly in the public sector. [1] The model is named after the authors ...

  4. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...

  5. Medication Administration Record - Wikipedia

    en.wikipedia.org/wiki/Medication_Administration...

    A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...

  6. Change-of-shift report - Wikipedia

    en.wikipedia.org/wiki/Change-of-shift_report

    A specific type of change-of-shift report is Nursing Bedside Shift Report in which the off going nurse provides change-of-shift report to the on coming nurse at the patient's bedside. [1] [5] [6] Since 2013, giving report at the patient bedside has been recommend by the Agency for Healthcare Research and Quality (AHRQ) to improve patient safety ...

  7. Case presentation - Wikipedia

    en.wikipedia.org/wiki/Case_presentation

    A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [1] [2] [3] Essential parts of a case presentation include:

  8. Nursing Minimum Data Set - Wikipedia

    en.wikipedia.org/wiki/Nursing_Minimum_Data_Set

    The Nursing Minimum Data Set ( NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations ...

  9. Evidence-based nursing - Wikipedia

    en.wikipedia.org/wiki/Evidence-based_nursing

    Prosecution. v. t. e. 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 ...

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