Complete Guide to Documentation / Edition 2
  • Complete Guide to Documentation / Edition 2
  • Complete Guide to Documentation / Edition 2

Complete Guide to Documentation / Edition 2

by Lippincott Williams & Wilkins
     
 

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

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Overview

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.

Product Details

ISBN-13:
9781582555560
Publisher:
Lippincott Williams & Wilkins
Publication date:
05/01/2007
Edition description:
Second Edition
Pages:
448
Product dimensions:
7.38(w) x 9.13(h) x (d)

Table of Contents

Contributors and consultants
Foreword
1Nursing documentation and the medical record2
2Legal and ethical implications of documentation15
3Performance improvement and reimbursement41
4Documentation systems58
5Documentation of the nursing process89
6Documentation in acute care148
7Documentation in long-term care189
8Documentation in home health care210
9Documentation in ambulatory care241
10Documentation of everyday events256
11Documentation of selected clinical specialties331
12Legally perilous charting practices359
13Computerized patient records378
14The future of automated documentation388
Commonly accepted abbreviations394
Commonly accepted symbols404
NANDA Taxonomy II codes406
JCAHO nursing care and documentation standards409
Outcomes and interventions for common nursing diagnoses412
Index430

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