Mastering Documentation / Edition 1

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Overview

No matter where you work, you'll find everything you need for fast, accurate, and safe documentation.

The book contains two-color illustrations.

Here is the complete guide for streamlining and improving nursing documentation for virtually every system. Nurses will find instructions for virtually every common and not-so-common charting method. More than 100 completed sample forms guide each action, and all information is organized by the nursing process for added convenience. From progress notes to protocols, nurses will find a wealth of easy-to-follow examples throughout the book. They'll avert career-threatening lawsuits by mastering "defensive charting," including how to protect patient privacy, how to document a patient's abusive behavior or refusal of treatment, and how to determine whether a patient is legally competent to give informed consent. Eye-catching symbols alert nurses to key facts throughout the book. Nurses will also find JCAHO-approved nursing abbreviations, ANA standards of nursing practice, and JCAHO and Medicare guidelines for nursing documentation. Contents include the medical record, legal and ethical concerns, reimbursement and quality assurance, documentation systems and methods, charting for each step of the nursing process, charting special situations, avoiding perils, and defending documentation.

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Editorial Reviews

Suzy Lockwood-Rayerm
This book describes in detail, and with illustration, every aspect of documentation in the medical record for a variety of patient care settings. The stated purpose is to identify important aspects of documentation that will result in accurate and legally defensible information in a patient's medical record. This is a worthy objective, given the litigious environment that permeates healthcare today, and this book meets, and in several areas exceeds, this objective. The target audience, while not specifically stated, appears to be nursing students and novice nurses. However, tenured nurses could use this book as a much-needed refresher of documentation rules that might have been forgotten. It would also prove useful for hospitals struggling to address risk management and quality issues of documentation for anyone required to record patient treatment in such a legal document. Additionally, education departments and nursing programs could use this text as a resource for the development of courses that seek to provide documentation instruction. The contributors, given their credentials and the settings they represent, demonstrate experience in issues of documentation. The standard topics of documentation in a variety of healthcare settings are covered. Documentation principles and themes are effectively summarized using numerous figures, tables, and examples. The strength of the text is in its coverage of the legal and ethical aspects of charting. An extensive list of commonly accepted abbreviations are provided, as well as an appendix which details guidelines for documentation related to NANDA. These specific appendixes make up for the shortcomings demonstrated in the glossary.Overall, this is a well-written text that reviews every aspect of documentation in nursing. Reviewed against other texts, it successfully blends illustrations with explanations. Given the inclusion of current documentation systems and focus on areas of growth in healthcare, the replacement of previous editions seems warranted.
Nancy G. Bruffey
This is a new book that provides a comprehensive and unique perspective to the entire documentation process. Information includes documentation attributes, requirements, advantages, and disadvantages for documenting nursing assessments and nursing care in a wide variety of settings using an equally wide variety of documentation methods. Also included is an excellent overview of the legal process related to malpractice lawsuits. The purpose of this book is to provide a comprehensive resource on the various documentation processes and requirements faced by all practicing nurse professionals. This reference is targeted toward the nurse in practice, but would be a valuable source of information for all nurses, from the novice student to the most seasoned professional. The multiple illustrations and colored page tab reference guide in this book foster its use as a quick reference tool. However, the inclusion of many detailed examples, illustrations and additional inside information about the entire documentation process promotes this book as an essential reading and resource guide for all nurses. Although the end of chapter references are sometimes scant and dated, the information is more than enough to stimulate the interested reader to initiate a more thorough review of updated resources where needed. True to the title, Mastering Documentation is an excellent resource for mastering the sometimes troublesome and tedious nursing task of documentation. This timely, accurate, and comprehensive guide for nursing documentation also provides information beyond the essentials, using author insight, case examples, multiple illustrations, diagrams, and tables The entiredocumentation process is clearly presented, from the initial entry on a patient's record to the potential legal battles over malpractice.
Doody's Review Service
Reviewer: Suzy Lockwood-Rayerm, RN, MSN (Texas Christian University)
Description: This book describes in detail, and with illustration, every aspect of documentation in the medical record for a variety of patient care settings.
Purpose: The stated purpose is to identify important aspects of documentation that will result in accurate and legally defensible information in a patient's medical record. This is a worthy objective, given the litigious environment that permeates healthcare today, and this book meets, and in several areas exceeds, this objective.
Audience: The target audience, while not specifically stated, appears to be nursing students and novice nurses. However, tenured nurses could use this book as a much-needed refresher of documentation rules that might have been forgotten. It would also prove useful for hospitals struggling to address risk management and quality issues of documentation for anyone required to record patient treatment in such a legal document. Additionally, education departments and nursing programs could use this text as a resource for the development of courses that seek to provide documentation instruction. The contributors, given their credentials and the settings they represent, demonstrate experience in issues of documentation.
Features: The standard topics of documentation in a variety of healthcare settings are covered. Documentation principles and themes are effectively summarized using numerous figures, tables, and examples. The strength of the text is in its coverage of the legal and ethical aspects of charting. An extensive list of commonly accepted abbreviations are provided, as well as an appendix which details guidelines for documentation related to NANDA. These specific appendixes make up for the shortcomings demonstrated in the glossary.
Assessment: Overall, this is a well-written text that reviews every aspect of documentation in nursing. Reviewed against other texts, it successfully blends illustrations with explanations. Given the inclusion of current documentation systems and focus on areas of growth in healthcare, the replacement of previous editions seems warranted.

3 Stars from Doody
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Product Details

  • ISBN-13: 9780874347494
  • Publisher: Lippincott Williams & Wilkins
  • Publication date: 1/28/1995
  • Edition description: Older Edition
  • Edition number: 1
  • Pages: 406
  • Product dimensions: 8.36 (w) x 10.24 (h) x 1.37 (d)

Table of Contents

Contributors
Acknowledgments
Foreword
1 Nursing Documentation and the Medical Record 1
2 Legal and Ethical Implications of Documentation 17
3 Quality Management and Reimbursement 43
4 Documentation Systems 61
5 Documentation in Acute Care 103
6 Documentation in Long-term Care 145
7 Documentation in Home Care 181
8 Documentation of the Nursing Process 207
9 Documentation of Everyday Events 265
10 Legally Perilous Charting Practices 325
11 Malpractice Lawsuits 343
A NANDA Taxonomy I, Revised 362
B Documentation Guidelines for Common Nursing Diagnoses 365
C ANA Standards of Nursing Practice 392
D JCAHO Nursing Care and Documentation Standards 396
E Nursing Organizations 399
F Commonly Accepted Abbreviations 405
G Commonly Accepted Symbols 414
Glossary 416
Index 420
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