Description
This portable reference is a timesaving guide on how to enhance charting skills, avoid legal pitfalls, and ensure that a complete and accurate record is created every time. Reviews fundamental aspects of charting, nursing process, legal and professional requirements, guidelines for developing a solid plan of care, and the variety of charting forms currently in use, including computerized charting. Completed forms show exactly how todocument assessment, intervention, and evaluation. Also addresses the specific requirements for charting in acute care, home care, and long-term care and rehabilitation. Appendices include NANDA Taxonomy II, as well as common abbreviations and symbols.
Features
--Documentation guidelines for virtually every patient situation in a wide range of health care settings (outpatient, hospital, home, and long-term care)
--Completed documentation forms showing the nurse exactly how to document assessment, interventions, and evaluation
--Examples of all documentation methods such as progress notes, graphic forms, and flow sheets
--Guidelines for every documentation system including computerized charting
--Tips for enhancing charting skills
--Guidance on avoiding legal pitfalls
--Logos:
--Timesaver - pointers that help the nurse save time
--ChartQuik - completed forms
--Checklist - suggests ways to improve documentation
--Warning - information to help avoid lawsuits
--SkillCheck - self-test quiz at the end of each chapter
--Appendices:
--Common abbreviations and symbols
--NANDA taxonomy 2
--Selected references
--Completed documentation forms showing the nurse exactly how to document assessment, interventions, and evaluation
--Examples of all documentation methods such as progress notes, graphic forms, and flow sheets
--Guidelines for every documentation system including computerized charting
--Tips for enhancing charting skills
--Guidance on avoiding legal pitfalls
--Logos:
--Timesaver - pointers that help the nurse save time
--ChartQuik - completed forms
--Checklist - suggests ways to improve documentation
--Warning - information to help avoid lawsuits
--SkillCheck - self-test quiz at the end of each chapter
--Appendices:
--Common abbreviations and symbols
--NANDA taxonomy 2
--Selected references
About the Author(s)
Specs
- Product Format: Spiralbound
- ISBN: 9781582551777
- Trim Size: 5 x 8
- Pages: 224
- Pub Date: Jul 11, 2002
- Weight: 1.0
Associated Specialties
