Complete Guide to Documentation / Edition 1

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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: 5/28/2003
  • Edition description: Older Edition
  • Edition number: 1
  • Pages: 448
  • Product dimensions: 7.14 (w) x 9.76 (h) x 1.18 (d)

Table of Contents

  1. Part I: Fundamentals

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

    Part II: Documentation for every practice setting

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

    Part III: Documentation in action

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

    Part IV: Computerized documentation

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