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Complete Guide to Documentation / Edition 2

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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.

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.

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Product Details

  • ISBN-13: 9781582555560
  • Publisher: Lippincott Williams & Wilkins
  • Publication date: 5/1/2007
  • Edition description: Second Edition
  • Edition number: 2
  • Pages: 448
  • Sales rank: 418,740

Table of Contents

Contributors and consultants
Foreword
1 Nursing documentation and the medical record 2
2 Legal and ethical implications of documentation 15
3 Performance improvement and reimbursement 41
4 Documentation systems 58
5 Documentation of the nursing process 89
6 Documentation in acute care 148
7 Documentation in long-term care 189
8 Documentation in home health care 210
9 Documentation in ambulatory care 241
10 Documentation of everyday events 256
11 Documentation of selected clinical specialties 331
12 Legally perilous charting practices 359
13 Computerized patient records 378
14 The future of automated documentation 388
Commonly accepted abbreviations 394
Commonly accepted symbols 404
NANDA Taxonomy II codes 406
JCAHO nursing care and documentation standards 409
Outcomes and interventions for common nursing diagnoses 412
Index 430
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