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Doody's Review ServiceReviewer: Carole Ann Kenner, PhD, RN, FAAN (The College of New Jersey)
Description: In this quick handbook the focus is on the medical/surgical patient and the accompanying documentation of the care received. New information on critical assessment of care, red flags that practice nurses need to be aware of when charting their findings, and responses to treatment are included in this third edition.
Purpose: The purpose is to facilitate succinct documentation to assist the nurse in charting the care rendered and minimizing the time required in this process.
Audience: The primary audience is practicing staff nurses. This book could also be used in schools of nursing for undergraduate senior students. The author is a leading authority in the areas of documentation, standard writing, and home care standards.
Features: The goals/measurable outcomes of care and the assessment of patient problems are outlined in this book. Examples of medical complication findings, nursing diagnoses (using NANDA), patient, family, and educational resources, and other services are provided, as are discharge outcomes, educational resources, and considerations for best practices. There is little applicability of the content for the pediatric or maternal child population, but that is not the emphasis of this book.
Assessment: There are few books that truly address a quick, thorough documentation process, and none of the current texts do it as a handbook. This is a high quality, user friendly book. The addition of special care documentation is good, but the focus is only on the dying, hospice, or psychiatric patient. This new edition has updated information, including the new critical assessment section with coverage of patient responses to treatments and red flag indicators. These are good features that also illustrate the need for good documentation for quality care and legal issues.