Documentation in Action

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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.

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.

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Editorial Reviews

Doody's Review Service
Reviewer: Josie Martin Bowman, RN, MSN, DSN (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.
From The Critics
Reviewer: Josie Martin Bowman, RN, MSN, DSN (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.

3 Stars from Doody
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Product Details

  • ISBN-13: 9781582554129
  • Publisher: Lippincott Williams & Wilkins
  • Publication date: 3/1/2005
  • Format: Spiral Bound
  • Edition description: New Edition
  • Pages: 416
  • Sales rank: 990,061

Table of Contents

1 Documenting everyday events 1
2 Documenting from admission to discharge 93
3 Legal and ethical implications of documentation 157
4 Legally perilous documentation 179
5 Computerized patient records 199
6 Documentation in acute care 213
7 Documentation in selected clinical specialty areas 267
8 Documentation in ambulatory care 303
9 Documentation in long-term care 317
10 Documentation in home health care 343
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