Nursing Documentation: Legal Focus across Practice Settings

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Overview

This book is intended to meet the needs of students and clinicians in determining how they should be recording their practice and what the legal implications of these records may be.

The authors first examine the realm of nursing documentation, including the legal implications of current methods of recording. In Part II the book presents the basis for liability in terms of nursing negligence and risk management. The third section explores documentation and its legal implications with respect to the delegation of patient care and across the range of in-patients and outpatient settings.

The book contains black-and-white illustrations.

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Editorial Reviews

Ann Schmidt Luggen
"It is the only book of its kind to combine legal issues with charting methods and an extensive review of practice settings where documentation varies greatly . . . . This is a little book chock-filled with useful information, tables, examples and charts . . . . In the back of the book is a good glossary and a list of legal case references."
Krysia Warren Hudson
This book, focusing on nursing documentation and the legal implications surrounding this key nursing activity, is useful to the practicing nurse. The author's use of case studies to illustrate important points is particularly helpful. The author feels that the profession of nursing is expanding both in scope and practice settings with a concomitant expansion in the types of nursing documentation and the legal issues surrounding the charting process. Thus, this book is attempting to address this growing issue. This is a worthwhile objective and the author is able to meet this objective, The audience ranges from beginning nursing students to advanced practice nurses. The author, a legal consultant, is a credible authority on the topic. Topics covered include types of charting and common charting problems, nursing negligence issues and risk management, the role of documentation in both of these areas, essentials of documentation in a variety of different settings, advanced practice documentation issues, and the future of nursing documentation. The use of case studies to illustrate key points is a clear strength of this book and should help the reader to more readily understand the information presented. The information presented is accurate but, at times, does not flow easily. This book is very valuable for any nurse seeking to improve documentation skills or to gain a clearer understanding of the legal implications inherent in the charting process.
From The Critics
Reviewer: Krysia Warren Hudson, MS, RNC (Johns Hopkins University School of Nursing)
Description: This book, focusing on nursing documentation and the legal implications surrounding this key nursing activity, is useful to the practicing nurse. The author's use of case studies to illustrate important points is particularly helpful.
Purpose: The author feels that the profession of nursing is expanding both in scope and practice settings with a concomitant expansion in the types of nursing documentation and the legal issues surrounding the charting process. Thus, this book is attempting to address this growing issue. This is a worthwhile objective and the author is able to meet this objective,
Audience: The audience ranges from beginning nursing students to advanced practice nurses. The author, a legal consultant, is a credible authority on the topic.
Features: Topics covered include types of charting and common charting problems, nursing negligence issues and risk management, the role of documentation in both of these areas, essentials of documentation in a variety of different settings, advanced practice documentation issues, and the future of nursing documentation. The use of case studies to illustrate key points is a clear strength of this book and should help the reader to more readily understand the information presented. The information presented is accurate but, at times, does not flow easily.
Assessment: This book is very valuable for any nurse seeking to improve documentation skills or to gain a clearer understanding of the legal implications inherent in the charting process.
Booknews
Meets the needs of nursing students and clinicians in determining how they should record their practice and what the legal implications of those records may be. Combines coverage of legal issues with charting methods and an extensive review of practice settings where documentation varies greatly, and identifies the basics of nursing liability in areas of written communications and issues where verbal reporting is necessary. Contains sections on communications in nursing practice, the basis for liability, documentation in practice settings, and a national health information systems for the 21st century. Includes sample forms, legal case references, and a glossary. Paper edition (unseen), $29.95. Annotation c. Book News, Inc., Portland, OR (booknews.com)

4 Stars! from Doody
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Product Details

  • ISBN-13: 9780761910718
  • Publisher: SAGE Publications
  • Publication date: 5/6/1999
  • Pages: 308
  • Product dimensions: 7.38 (w) x 10.28 (h) x 0.93 (d)

Table of Contents

PART ONE: COMMUNICATIONS IN NURSING PRACTICE
Introduction to Documentation, Liability and Nursing Practice - Sue E Meiner
Current Approaches in Charting - Sue E Meiner
Computer-Based Patient Records - Elizabeth C Mueth
Common Problems of Recording in the Medical Record - Sue E Meiner
Issues Requiring Reporting and Recording - Sue E Meiner with Linda Steele
Reporting Health and Safety Issues - Sue E Meiner
PART TWO: THE BASIS FOR LIABILITY
Nursing Negligence Issues - Alice G Rini
Risk Management and Claims Prevention - Alice G Rini
PART THREE: DOCUMENTATION IN PRACTICE SETTINGS
Staffing and Delegation of Patient Care - Robyn Levy and Sue E Meiner
Recording Patient Care in the Emergency Department - Sue E Meiner
Recording Patient Care in the Critical Care Unit - Sue E Meiner
Recording Patient Care in the Obstetric Unit - Sue E Meiner
Recording Patient Care in the Pediatric Unit - Sue E Meiner
Recording Patient Care in Perioperative Nursing - Linda L Zinser-Eagle and Sue E Meiner
Recording Patient Care in Psychiatric/Mental Health Nursing - Sue E Meiner
Communications in Community and Home Health Care Nursing - Sue E Meiner with Nancy Kuhrick and Marilee Kuhrick
Documentation in Extended and Long-Term Care Nursing - Sue E Meiner
Advanced Practice Nursing Issues - Linda Steele with Sue E Meiner
Nursing Educators, Administration, and Nursing Education - Alice G Rini
Managed Care - Sue E Meiner
PART FOUR: A NATIONAL HEALTH INFORMATION SYSTEM FOR THE 21ST CENTURY
Dialogue for a National Health Information System - Sue E Meiner and Elizabeth C Mueth

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