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  2. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    SOAP note. 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 ...

  3. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    An example of a nursing care plan in an Australian residential aged care home Electronic nursing documentation systems have the potential to improve the quality of documentation structure and format, process and content in comparison with paper-based documentation, as demonstrated in a comparative study of electronic and paper-based nursing ...

  4. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    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.

  5. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress note. Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [ 1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP ...

  6. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    The Clinical Care Classification ( CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [ 1]

  7. SMART criteria - Wikipedia

    en.wikipedia.org/wiki/SMART_criteria

    SMART criteria. A variant of the SMART model. 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.

  8. Action plan - Wikipedia

    en.wikipedia.org/wiki/Action_plan

    The Council of Europe has organized some action plans for helping its member states. An example of this is the Council of Europe Action Plan for the Republic of Moldova 2021–2024, created with the purpose of improving Moldova's situation on democracy, human rights and rule of law and its state institutions and legislation. [15]

  9. Nursing Outcomes Classification - Wikipedia

    en.wikipedia.org/wiki/Nursing_Outcomes...

    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 ...

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