Chart Smart The A-to-Z Guide to Better Nursing Documentation

by Unknown

• ISBN13: 9781582550961
• ISBN10: 1582550964
• Format: Paperback
• Copyright: 2001-07-03
• Publisher: Spring House

Summary

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 care, extended care, and long-term care, 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.

Table of Contents

Contributors and consultants	vii
Foreword	ix
Documentation (in alphabetical order)	1	(466)
Appendices
A Documentation systems	432	(17)
B JCAHO nursing care and documentation standards	449	(5)
C Commonly accepted abbreviations	454	(8)
D Commonly accepted symbols	462	(2)
E NANDA Taxonomy II codes	464	(3)
Selected references	467	(1)
Index	468