Examlex
The nurse recognizes that the first step in understanding the health care needs of another person is:
Nursing Diagnosis
A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes, which provides the basis for selecting nursing interventions.
Narrative Charting
A method of documentation that involves a detailed written account of a patient's condition, care, and response during a healthcare encounter.
PIE Documentation
A method of recording nursing care, standing for Problem, Intervention, and Evaluation, aimed at providing detailed and structured documentation.
SOAP Documentation
An organized method of documentation in healthcare that includes four sections: Subjective, Objective, Assessment, and Plan.
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