Nursing Know-How: Charting Patient Care

Nursing Know-How: Charting Patient Care 9780781791946
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Author(s): Springhouse 
Publication Date: Apr 25, 2008
Availability: IN STOCK
Format: Book
ISBN/ISSN: 9780781791946
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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.

Features

--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

About the Author(s)

Specs

  • Product Format: Flexible Binding
  • ISBN: 9780781791946
  • Trim Size: 6 x 9
  • Pages: 416
  • Pub Date: Apr 25, 2008
  • Weight: 1.0

Table of contents

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 II Documentation (in alphabetical order)

Selected references

Index