Complete Guide to Documentation / Edition 1

Complete Guide to Documentation / Edition 1

by Lippincott Williams & Wilkins, Springhouse Publishing Company Staff
     
 

ISBN-10: 158255238X

ISBN-13: 9781582552385

Pub. Date: 05/28/2003

Publisher: Lippincott Williams & Wilkins

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,

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Overview

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, 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. Special features of the guide include filled-in documentation forms and samples, regulatory guidelines relating to documentation, and a glossary. Appendices cover approved nursing abbreviations, standards of nursing practice, and guidelines for documenting common nursing diagnoses. Graphic icons are used throughout the book to draw attention to tips on smarter charting, technology’s use in documentation, checklists, court cases, legal information, and sample documentation forms.

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Product Details

ISBN-13:
9781582552385
Publisher:
Lippincott Williams & Wilkins
Publication date:
05/28/2003
Edition description:
Older Edition
Pages:
448
Product dimensions:
7.14(w) x 9.76(h) x 1.18(d)

Table of Contents

    Part I: Fundamentals

  1. Nursing Documentation and the medical record
  2. Legal and ethical implications of documentation
  3. Quality management and reimbursement
  4. Documentation systems
  5. Documentation of the nursing process

    Part II: Documentation for every practice setting

  6. Documentation in acute care
  7. Documentation in long-term car
  8. Documentation in home care
  9. Documentation in outpatient and ambulatory care

    Part III: Documentation in action

  10. Documentation of everyday events
  11. Documentation of selected clinical specialties
  12. Legally perilous documentation practices

    Part IV: Computerized documentation

  13. Computerized patient records
  14. The future of automated documentation

Appendices
  1. JCAHO-approved nursing abbreviations
  2. JCAHO nursing care and documentation standards
  3. Commonly accepted abbreviations and symbols for documentation
  4. Documentation guidelines for common nursing diagnoses
Index

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