The eNursing Summary contains data sets related to specific clinical enviroment as a process to create safe, effective communication, ensuring continuity as the patient moves through care transitions. Transitions, or "hand-offs", occur multiple times each day in a hospital and at every change of care location.
status
ACTIVE
Fully-Specified Name
component
Summary note
property
Find = Finding
time
Pt = Point in time: To identify measures at a point in time. This is a synonym for “spot” or “random” as applied to urine measurements.
system
{Setting}
scale
Doc = Document: A document that could be in many formats (XML, narrative, etc.)
method
Nurse
Additional Names
short name
DOC.ONT; Document; Encounter; Evaluation and management; Evaluation and management note; Finding; Findings; notes; nursing; Point in time; Random; Visit note