Documentation in Action

Documentation in Action

by Lippincott Williams & Wilkins
     
 

ISBN-10: 1582554129

ISBN-13: 9781582554129

Pub. Date: 03/01/2005

Publisher: Lippincott Williams & Wilkins

Designed for rapid on-the-job reference, Documentation in Action offers comprehensive, authoritative, practice-oriented, up-to-the-minute guidelines for documenting every situation in every nursing practice setting and important nursing specialties. Need-to-know information is presented in bulleted lists, charts, flow sheets, sidebars, and boxes, with icons

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Overview

Designed for rapid on-the-job reference, Documentation in Action offers comprehensive, authoritative, practice-oriented, up-to-the-minute guidelines for documenting every situation in every nursing practice setting and important nursing specialties. Need-to-know information is presented in bulleted lists, charts, flow sheets, sidebars, and boxes, with icons and illustrative filled-in samples.

Coverage includes documentation for care of patients with various diseases, complications, emergencies, complex procedures, and difficulties involving patients, families, and other health care professionals. Suggestions are given for avoiding legal pitfalls involving telephone orders, medication reactions, patients who refuse care, and much more. A section addresses computerized documentation, HIPAA confidentiality rules, use of PDAs, nursing informatics, and electronic innovations that will soon be universal.

Product Details

ISBN-13:
9781582554129
Publisher:
Lippincott Williams & Wilkins
Publication date:
03/01/2005
Edition description:
New Edition
Pages:
416
Product dimensions:
5.25(w) x 8.19(h) x (d)

Table of Contents

1Documenting everyday events1
2Documenting from admission to discharge93
3Legal and ethical implications of documentation157
4Legally perilous documentation179
5Computerized patient records199
6Documentation in acute care213
7Documentation in selected clinical specialty areas267
8Documentation in ambulatory care303
9Documentation in long-term care317
10Documentation in home health care343

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