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Doody's Review ServiceReviewer: Josie Martin Bowman, RN, MSN, PhD (East Carolina University )
Description: This book presents a discussion of various types of documentation from the acute care setting to the community setting. Most of the documentation occurs in a handwritten format with a section on computerized charting.
Purpose: The focus is on helping nurses to document accurate and appropriate information that is "timely, addresses legal and ethical concerns, and serves as a true and complete record of a patient's care." The intent of the book is worthy due to the critical nature of documentation. It is essential that nurses chart correctly and in a timely fashion due to the nature of the healthcare environment.
Audience: The book was developed using consultants and contributors from various settings — schools of nursing, long-term care settings, and tertiary settings. Using a variety of individuals allowed each contributor to share unique expertise.
Features: The authors start with documenting everyday events, discussing documentation in everyday events, incidents and long-term care. The authors focus on documenting assessments, computer charting, and legal aspects. The completeness of the discussion in each area is a strength. There are various areas that are covered in more detail and these are highlighted in boxes or examples of charting.
Assessment: This is a useful book for student nurses, new graduates, and nurses documenting an unfamiliar procedure or event. Since documentation must be complete and accurate, this book provides information on how to make this happen.