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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 ...
e. The Terri Schiavo case was a series of court and legislative actions in the United States from 1998 to 2005, regarding the care of Theresa Marie Schiavo (née Schindler) ( / ˈʃaɪvoʊ /; December 3, 1963 – March 31, 2005), a woman in an irreversible persistent vegetative state. Schiavo's husband and legal guardian argued that Schiavo ...
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]
Gordon's functional health patterns. Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient. The following areas are assessed through questions asked by the nurse and medical examinations to provide an overview of ...
Differential diagnosis. In healthcare, a differential diagnosis ( DDx) is a method of analysis that distinguishes a particular disease or condition from others that present with similar clinical features. [ 1] Differential diagnostic procedures are used by clinicians to diagnose the specific disease in a patient, or, at least, to consider any ...
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 ...
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.
Index case. The index case or patient zero is the first documented patient in a disease epidemic within a population, [ 1] or the first documented patient included in an epidemiological study. [ 2] It can also refer to the first case of a condition or syndrome (not necessarily contagious) to be described in the medical literature, whether or ...