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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:
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 ...
Definition. A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or ...
A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [ 1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient. All data on each patient participating in a clinical trial are held and/or documented in the CRF ...
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]
The critical incident technique (or CIT) is a set of procedures used for collecting direct observations of human behavior that have critical significance and meet methodically defined criteria. These observations are then kept track of as incidents, which are then used to solve practical problems and develop broad psychological principles.
PICO process. The PICO process (or framework) is a mnemonic used in evidence-based practice (and specifically evidence-based medicine) to frame and answer a clinical or health care related question, [ 1] though it is also argued that PICO "can be used universally for every scientific endeavour in any discipline with all study designs". [ 2]
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 ...