Nursing Documentation Handbook / Edition 3

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Overview

This pocket-size guide saves nurses precious time while ensuring that a complete patient record is created and that legal, quality assurance, and reimbursement requirements are met. This handbook provides specific verbiage for charting patient progress, change or tasks accomplished for approximately 50 common problems. The new third edition has been completely updated to include Critical Assessment Findings, Subjective Findings for Documentation, Resources for Care and Practice, Legal Considerations, Time Saving Tips, and new Managed Care information. Plus, roughly 15 additional common problems and diagnoses have been added making this practical resource more valuable than ever. Diagnoses are in alphabetical order allowing for fast and easy access.

The book contains no figures.

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Editorial Reviews

Doody's Review Service
Reviewer: Carole A. Kenner, PhD, RN, FAAN (Council of International Neonatal Nurses)
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.
Carole Kenner
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. The purpose is to facilitate succinct documentation to assist the nurse in charting the care rendered and minimizing the time required in this process. 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. 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. 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 needfor good documentation for quality care and legal issues.

3 Stars from Doody
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Product Details

  • ISBN-13: 9780323010979
  • Publisher: Elsevier Health Sciences
  • Publication date: 4/26/2000
  • Format: Spiral Bound
  • Edition number: 3
  • Pages: 391
  • Product dimensions: 5.07 (w) x 7.35 (h) x 1.16 (d)

Table of Contents

PART ONE: The Principles of Documentation · Documentation: An Overview · The Patient Record · Systems of Nursing Documentation · The Joint Commission on Accreditation of Healthcare Organizations Standards Related to Documentation · American Nurses' Association Standards of Care · PART TWO: Medical-Surgical Care Documentation Guidelines · Acquired Immune Deficiency Syndrome (AIDS) · Acute Myocardial Infarction · Alzheimer's Disease and Other Dementias · Amputation · Angina · Asthma · Brain Tumor · Cancer Care · Cardiac Surgical Care · Cataract Care · Cerebrovascular Accident · Chemotherapy · Chronic Obstructive Pulmonary Disease · Congestive Heart Failure · Decubitus Ulcer · Diabetes Mellitus · Dialysis · Diarrhea · Enteral Care · Fracture Care · Gastrostomy Tube · Hypertension · Immobile Patient · Impaction · Intestinal Obstruction · Intravenous Therapy Care · Mastectomy Care · Osteoarthritis · Ostomy · Pain Management · Peripheral Vascular Disease · Pneumonia · Sickle Cell Anemia · Surgical Care · Tracheostomy Care · Tuberculosis · Urinary Catheter Care · Wound Care · PART THREE: Specialty Care Documentation Guidelines · Hospice Care · Maternal-Child Care · APPENDIXES: A) NANDA-Approved Nursing Diagnoses B) Services Provided by Other Disciplines C) Abbreviations D) Resources · BIBLIOGRAPHY

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