Nursing Know-How: Charting Patient Care

Nursing Know-How: Charting Patient Care

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Publication Date: 2008
Availability: In Stock
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ISBN/ISSN: 9780781791946

Description

Nursing Know-How: Charting Patient Care offers how-to guidance on the latest techniques and trends in documentation, equipping nurses with the "know-how" to efficiently and accurately document patient care admission to discharge. The book is written in paragraph and bulleted format, with hundreds of sample filled-in forms and narrative notes that demonstrate the best and safest charting techniques.

Know-How icons offer expert advice on how to document. Case Clip icons present clinical scenarios involving specific situations, and identify the role that a rapid response team plays in responding to the situation. Legal Lookout icons present legal advice about documentation and real-world court cases where careful nursing documentation is particularly vital.

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--Time-saving strategies for documentation from admission to discharge.
--Part II has A-to-Z organization for practice-oriented use
--Hundreds of filled-in sample forms and excerpts of narrative notes, demonstrating the best and safest charting techniques
--Open, highly bulleted format with each topic starting on a new page
--Quick-scan tables covering dangerous abbreviations to avoid, different charting systems, and more
--Tips for complying with the latest HIPAA and Joint Commission guidelines
--The latest advice on electronic medical records
--Icons:
  • Know-How : expert advice on how to document
  • Case Clip: clinical scenarios that show the best way to document specific situations and identify the role that a rapod reponse team plays in responding to the situation
  • Legal Lookout: legal advice about documentation and real-world court cases where careful nursing documentation saved, or would have saved, the day

ISBN/ISSN: 9780781791946
Product Format: Flexible Binding
Trim Size: 6 x 9
Pages: 416
Pub Date: 2008
Weight: 1.25

Contributors and consultants

Part I Documentation and legal issues

Chapter 1 Documenting from admission to discharge

Chapter 2 Legal and ethical implications of documentation

Chapter 3 Legally perilous documentation

Chapter 4 Electronic medical records

Chapter 5 Documentation in acute care

Part IIDocumentation (in alphabetical order)

Selected references

Index

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