Model of Nursing Documentation

Source Oriented Record (SOR)

Everyone is a traditional Notes / sections / resource has its own record or separately. Consisting of five components:

1. Admission sheet
2. Doctor's instruction sheet
3. Medical history sheet
4. Note nurses
5. Notes and special reports
6. Graphics card / records

Problem Oriented Record (POR)

Is an effective tool to assist health care teams (Introduced by Dr. Lawrence Weed, USA). Identify patient problems, plan therapy, diagnosis and counseling and evaluating and reviewing progress.

Comments

The Concept of Mental Nursing

NursingNetwork ,--The Concept of Mental Nursing or Nursing the psyche according to American Nurses Associations (ANA) is a special area of nursing practice that uses the science of human behavior as a basis and uses oneself therapeutically in improving, maintaining, restoring the client's mental health and mental health of the community in which the client is located (American Nurses Associations). Mental health is not just a state of mental disorder, but it contains various characteristics about direct care, communication and management, is positive describes harmony and balance of the psyche. Nursing the psyche is a professional nursing service based on the science of behavior, the science of mental nursing in humans throughout the life cycle with a maladaptive social-psycho response caused by bio-psycho-social disorder, using self and soul nursing therapy (therapeutic communication and modal therapy mental health nursing) through a nursing process approach to impr...

Definition of a Nursing Diagnosis

NursingNetwork , - A nursing diagnosis is defined by NANDA International (2013) as a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community. New NANDA Nursing Diagnoses In this edition of NANDA nursing diagnosis list (2018-2020), seventeen new nursing diagnoses were approved and introduced. These new approved nursing diagnoses are: Readiness for enhanced health literacy Ineffective adolescent eating dynamics Ineffective child eating dynamics Ineffective infant eating dynamics Risk for metabolic imbalance syndrome Imbalanced energy field Risk for unstable blood pressure Risk for complicated immigration transition Neonatal abstinence syndrome Acute substance withdrawal syndrome Risk for acute substance withdrawal syndrome Risk for surgical site infection Risk for dry mouth Risk for venous thromboembolism Risk for female genital mutilation Risk for occupati...

The concept of Basic Human Needs According to Abraham Maslow

Based on the concept of basic needs, the nurse in charge in meet the basic needs of the client. Nurses are expected to view the client as a unique creature comprehensive in providing care. 1.Actualization Self Esteem 2.Belonging Self 3.Safety /Security Need Comprehensive means that in meeting basic needs of the client, not just focusing on meeting the physical needs or psychological only, but all aspects of the responsibility of the nurse.

Nursing

Search This Blog