Cover image for Complete guide to documentation.
Complete guide to documentation.
Lippincott Williams & Wilkins.
Publication Information:
Springhouse : Lippincott Williams & Wilkins, [2003]

Physical Description:
x, 437 pages : illustrations ; 25 cm
Nursing documentation and the medical record -- Legal and ethical implications of documentation -- Performance improvement and reimbursement -- Documentation systems -- Documentation of the nursing process -- Documentation in acute care -- Documentation in long-term care -- Documentation in home health care -- Documentation in ambulatory care -- Documentation of everyday events -- Documentation of selected clinical specialties -- Legally perilous documentation practices -- Computerized patient records -- The future of automated documentation.
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RT50 .C65 2003 Adult Non-Fiction Non-Fiction Area

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This comprehensive documentation reference is the most up-to-date book of its kind written for nurses. Complete Guide to Documentation is organized into four sections. Section 1 presents an overview of documentation basics, including the medical record, elements of good documentation, policies affecting documentation, legal and ethical considerations, quality management and reimbursement, documentation systems, and computerized documentation. Section 2 discusses documentation for acute care, outpatient or ambulatory care, home care, and long-term, extended care, and rehabilitation. Section 3 provides sample documentation for several clinical situations. Section 4 discusses how to document care given in selected clinical specialties and current documentation trends. Special features of the guide include filled-in documentation forms and samples, regulatory guidelines relating to documentation, and a glossary. Appendices cover approved nursing abbreviations, standards of nursing practice, and guidelines for documenting common nursing diagnoses. Graphic icons are used throughout the book to draw attention to tips on smarter charting, technology's use in documentation, checklists, court cases, legal information, and sample documentation forms.

Table of Contents

Contributors and consultantsp. vii
Forewordp. ix
Part I Fundamentalsp. 1
1 Nursing documentation and the medical recordp. 2
2 Legal and ethical implications of documentationp. 15
3 Performance improvement and reimbursementp. 41
4 Documentation systemsp. 58
5 Documentation of the nursing processp. 89
Part II Documentation for Every Practice Settingp. 147
6 Documentation in acute carep. 148
7 Documentation in long-term carep. 189
8 Documentation in home health carep. 210
9 Documentation in ambulatory carep. 241
Part III Documentation in Actionp. 255
10 Documentation of everyday eventsp. 256
11 Documentation of selected clinical specialtiesp. 331
12 Legally perilous charting practicesp. 359
Part IV Computerized Documentationp. 377
13 Computerized patient recordsp. 378
14 The future of automated documentationp. 388
Commonly accepted abbreviationsp. 394
Commonly accepted symbolsp. 404
NANDA Taxonomy II codesp. 406
JCAHO nursing care and documentation standardsp. 409
Outcomes and interventions for common nursing diagnosesp. 412
Indexp. 430