Second edition
Thoroughly updated for its Second Edition, Complete Guide to Documentation provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems.
This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management.
Features:
- Hundreds of filled-in sample forms show specific content and wording
- Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations
- Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses
Contents
Fundamentals
- Nursing documentation and the medical record
- Legal and ethical implications of documentation
- Performance improvement and reimbursement
- Documentation systems
- Documentation of the nursing process
Documentation in Practice Settings
- Documentation in acute care
- Documentation in long-term care
- Documentation in home-health care
- Documentation in ambulatory care
Documentation in Action
- Documentation of everyday events
- Documentation of selected clinical specialties
- Legally perilous charting practices
Electronic Documentation
- Electronic medical records
- Electronic nursing documentation
Appendix
Index
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