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, 438 pages : illustrations, forms ; 24 cm

Edition:

Second edition.

Place of Publication:

Philadelphia : Wolters Kluwer Health/Lippincott Williams & Wilkins, [2008]

Summary:

Thoroughly updated for its Second Edition, this comprehensive reference 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. 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:

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 charting practices

Electronic patient records

Electronic nursing documentation.

Notes:

Includes bibliographical references and index.

ISBN:

9781582555560

OCLC:

84730279

Online:

Publisher description