Nursing Documentationby Patricia W. Iyer, Nancy Hand Camp
NURSING DOCUMENTATION: A NURSING PROCESS APPROACH clearly and concisely provides guidelines for appropriate and careful documentation of care. Accurate documentation shows managed care companies that patients receive adequate care and that health care providers are controlling costs and resources. In addition, it plays a large role in how third party payors… See more details below
NURSING DOCUMENTATION: A NURSING PROCESS APPROACH clearly and concisely provides guidelines for appropriate and careful documentation of care. Accurate documentation shows managed care companies that patients receive adequate care and that health care providers are controlling costs and resources. In addition, it plays a large role in how third party payors make payment or denial decisions. This new edition includes the latest changes and trends in nursing documentation as related to the newly restructured healthcare environment. Special attention focuses on the latest documentation issues specific to specialty settings, such as acute care, home care, and long-term care, and a variety of clinical specialties, such as obstetrics, pediatrics, and critical care.
* Applies principles of documentation using practical examples, scenarios, and case studies.
• Organizes documentation concerns based on the five-step nursing process.
• Incorporates the most current JCAHO standards and NANDA taxonomy as they relate to documenting care.
• Includes Home Care Documentation section, which provides information about unique considerations in documentation of home care, such as proper documentation for reimbursement, computerized patient records, and continuity of services.
• Contains Long-Term Care Documentation chapter, which focuses on specific documentation information for long-term care, including proper documentation for Medicare, Resident Assessment Protocols, and interdisciplinary care planning.
• Written in a clear and concise manner.
Description: This is an excellent, practical book with a clear presentation about documentation, both its general aspects and issues as well as specialty issues. The previous edition was published in 1995. This edition includes the recent changes in healthcare and their effects on documentation.
Purpose: This book provides content that will increase and update nurses' knowledge about documentation with a systematic overview of the essentials of documentation in all types of settings, from acute and home care to long-term care.
Audience: Students and nurses of all expertise levels who practice in a variety of specialties can benefit from this book. The authors and contributors have considerable clinical, education, and legal experience, which is demonstrated in the content.
Features: This is an excellent example of how the nursing process is demonstrated through documentation. The authors emphasize critical legal issues that are an important part of daily practice. The newest trends and issues are included, including charting systems, computerization, managed care, case management, and clinical pathways. Documentation in specialty areas such as psychiatry, emergency services, critical care, and maternal/child, as well as home care and long-term care nursing, are welcome additions to this third edition.
Assessment: This is a very useful book for the nursing profession and education. The forms used to illustrate content are excellent, as are the chapter formats and exhibits. These all add to the readability and usefulness of the content. As documentation is influenced by changes in the healthcare environment, it is important to have updated editions of this book.
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