This full-color handbook is a quick-reference guide to all aspects of documentation for every nursing care situation.

Lippincott Manual of Nursing Practice Series: Documentation covers current documentation systems and formats, including computerized documentation, and features scores of sample filled-in forms and in-text narrative notes illustrating everything from everyday occurrences to emergency situations.

Coverage includes:

• timesaving strategies for admission-to-discharge documentation in acute, outpatient, rehabilitation, long-term, and home care environments
• special documentation practices for selected clinical specialties: critical care, emergency, perioperative, maternal-neonatal, and psychiatric
• advice on legal safeguards
• dangerous abbreviations
• compliance with HIPAA guidelines and JCAHO requirements

Contents

1. Documenting everyday events
2. Documenting from admission to discharge
3. Legal and ethical implications
4. Legally perilous documentation
5. Computerized patient records
6. Documentation in acute care
7. Documentation in selected clinical specialty area
8. Documentation in ambulatory care
9. Documentation in long-term care
10. Documentation in home health care

Appendices

• NANDA-I taxonomy II
• Comparing documentation systems

Index

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