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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 ...
Clinical Care Classification System. 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]
Emergency nursing is a specialty within the field of professional nursing focusing on the care of patients who require prompt medical attention to avoid long-term disability or death. In addition to addressing "true emergencies," emergency nurses increasingly care for people who are unwilling or unable to get primary medical care elsewhere and ...
[[Category:Nursing templates]] to the <includeonly> section at the bottom of that page. Otherwise, add <noinclude>[[Category:Nursing templates]]</noinclude> to the end of the template code, making sure it starts on the same line as the code's last character.
An organizational chart, also called organigram, organogram, or organizational breakdown structure ( OBS ), is a diagram that shows the structure of an organization and the relationships and relative ranks of its parts and positions/jobs. The term is also used for similar diagrams, for example ones showing the different elements of a field of ...
Medication Administration Record. A Medication Administration Record [1] ( MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. The MAR is a part of a patient's permanent record on their medical ...
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