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Complete Guide to Documentation 2nd Edition by Lippincott Williams and Wilkins ISBN 9781582555560 1582555567

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Product details:

ISBN 10: 1582555567
ISBN 13: 9781582555560
Author:  Lippincott Williams and Wilkins

Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management.

Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.

Table of contents:

  1. Nursing documentation and the medical record
  2. Legal and ethical implications of documentation
  3. Performance improvement and reimbursement
  4. Documentation systems
  5. Documentation of the nursing process
  6. Documentation in acute care
  7. Documentation in long-term care
  8. Documentation in home health care
  9. Documentation in ambulatory care
  10. Documentation of everyday events
  11. Documentation of selected clinical specialties
  12. Legally perilous charting practices
  13. Electronic patient records
  14. Electronic nursing documentation

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