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Documentation & the nursing process / Lois White.
Holman Biotech Commons RT50 .W457 2003
Available
- Format:
- Book
- Author/Creator:
- White, Lois.
- Language:
- English
- Subjects (All):
- Nursing records--Handbooks, manuals, etc.
- Nursing records.
- Nursing Records.
- Medical Subjects:
- Nursing Records.
- Genre:
- Handbooks and manuals.
- Physical Description:
- xii, 189 pages : illustrations ; 22 cm
- Other Title:
- Documentation and the nursing process
- Place of Publication:
- Clifton Park, NY : Thomson/Delmar Learning, [2003]
- Summary:
- This handbook offers a thorough overview of nursing documentation and its importance within the context of the nursing process. Users learn the principles of effective documentation and methods of documenting and examine trends relevant to this aspect of nursing care.
- Contents:
- Unit 1 Nursing Process 1
- Historical Perspective 4
- The Nursing Process and Critical Thinking 6
- The Nursing Process and Problem Solving 9
- The Nursing Process and Decision Making 9
- The Nursing Process and Holistic Care 10
- Chapter 2 Assessment 15
- Purpose of Assessment 16
- Database 16
- Collecting Data 16
- Types of Assessment 16
- Comprehensive Assessment 17
- Focused Assessment 17
- Ongoing Assessment 17
- Sources of Data 19
- Types of Data 20
- Validating the Data 23
- Organizing the Data 23
- Hierarchy of Needs 24
- Body Systems Model 24
- Functional Health Patterns 25
- Theory of Self-Care 25
- Interpreting the Data 26
- Documenting the Data 26
- Chapter 3 Diagnosis 31
- Components of a Nursing Diagnosis 34
- Two-Part Statement 34
- Three-Part Statement 34
- Writing the Nursing Diagnosis Statement 35
- Types of Nursing Diagnoses 35
- Collaborative Problems 37
- Chapter 4 Planning and Outcome Identification 41
- Prioritizing the Nursing Diagnoses 42
- Goals 43
- Expected Outcomes 44
- Developing Specific Nursing Interventions 45
- Categories of Nursing Interventions 47
- Recording the Nursing Care Plan 47
- Chapter 5 Implementation 55
- Requirements for Effective Implementation 56
- Types of Nursing Interventions 57
- Documenting and Reporting Interventions 58
- Chapter 6 Evaluation 63
- Evaluation 63
- Nursing Audit 66
- Unit 2 Documentation 71
- Chapter 7 Documentation As Communication 73
- Purposes of Health Care Documentation 74
- Communication 75
- Education 75
- Research 79
- Legal and Practice Standards 80
- Informed Consent 80
- Advance Directives 82
- State Nursing Practice Acts 83
- Joint Commission on Accreditation of Healthcare Organizations 84
- Reimbursement 86
- Chapter 8 Principles of Effective Documentation 93
- Follow the Nursing Process 93
- Elements of Effective Documentation 95
- Accurate, Complete, and Objective 96
- Date and Time 96
- Use Appropriate Forms 98
- Identify the Client 98
- Write in Ink 98
- Use Standard Abbreviations 99
- Spell Correctly 99
- Write Legibly 99
- Correct Errors Properly 100
- Write on Every Line 100
- Chart Omissions 100
- Sign Each Entry 101
- Documenting a Medication Error 102
- Medication Incident Report 103
- Chapter 9 Methods of Documentation 109
- Narrative Charting 110
- Source-Oriented Charting 111
- Problem-Oriented Charting 111
- PIE Charting 112
- Focus Charting 112
- Charting by Exception 114
- Computerized Charting 115
- Point-of-Care Charting 117
- Critical Pathway 118
- Chapter 10 Forms for Recording Data 129
- Kardex 129
- Flow Sheets 131
- Nurses' Progress Notes 134
- Discharge Summary 136
- Chapter 11 Trends in Documentation 145
- Nursing Minimum Data Set 146
- Nursing Diagnoses 146
- Nursing Interventions Classification 147
- Nursing Outcomes Classification 149
- Chapter 12 Reporting 155
- Summary Reports 157
- Walking Rounds 157
- Telephone Reports and Orders 159
- Incident Reports 160
- Appendix A NANDA Nursing Diagnoses 2001-2002 167.
- Notes:
- Includes bibliographical references and index.
- ISBN:
- 0766850099
- OCLC:
- 49743666
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