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Doody's Review ServiceReviewer: Pamela J. Manning, RN (University of Colorado Health Sciences Center)
Description: This book clearly addresses the importance and necessity of accurate and complete documentation in every medical record. The book provides excellent case studies and figures that are easy to read and understand.
Purpose: This is a valuable resource for all managers as it addresses a wide range of documentation issues that managers and staff are faced with in every day situations. The book offers excellent tips on how to document, the importance of thorough documentation, and the impact documentation has on patients, staff, managers, as well as its financial and legal implications.
Audience: The book was written as a guide for nurse managers, but it is also appropriate for staff nurses. The author appears to be quite knowledgeable as the book is thorough in all aspects of documentation.
Features: The book covers a variety of documentation topics a nurse manager faces including but not limited to acceptable/unacceptable documentation, ways to improve documentation among staff, compliance and legal aspects, and developing documentation systems. One of the best features of the book is the use of case studies. They clearly reflect each of the chapter topics and could be used as teaching tools for staff nurses.
Assessment: As an RN lead case manager, I found this book very informative and useful. In my role, I am responsible for both patient documentation as it pertains to case management as well as staff training. I will use this book as a guide in not only the training but also chart auditing and role playing as it relates to documentation.