Complete guide to documentation.

Format:

Book

Contributor:

Lippincott Williams & Wilkins.

Language:

English

Subjects (All):

Nursing records.

Nursing care plans.

Nursing Records.

Documentation.

Forms and Records Control.

Medical Subjects:

Nursing Records.

Documentation.

Forms and Records Control.

Physical Description:

x, 437 pages : illustrations, forms ; 25 cm

Place of Publication:

Philadelphia ; London : Lippincott Williams & Wilkins, [2003]

Summary:

This comprehensive documentation reference is the most up-to-date book of its kind written for nurses. Complete Guide to Documentation is organized into four sections. Section 1 presents an overview of documentation basics, including the medical record, elements of good documentation, policies affecting documentation, legal and ethical considerations, quality management and reimbursement, documentation systems, and computerized documentation. Section 2 discusses documentation for acute care, outpatient or ambulatory care, home care, and long-term care, extended care, and long-term care, extended care, and rehabilitation. Section 3 provides sample documentation for several clinical situations. Section 4 discusses how to document care given in selected clinical specialties and current documentation trends.

Contents:

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 acute care

Documentation in long-term care

Documentation in home health care

Documentation in ambulatory care

Documentation of everyday events

Documentation of selected clinical specialties

Legally perilous documentation practices

Computerized patient records

The future of automated documentation.

Notes:

Includes bibliographical references and index.

ISBN:

158255238X

OCLC:

51586787