Documentation & the Nursing Process: A Review

by White, Lois

• ISBN13: 9780766850095
• ISBN10: 0766850099
• Format: Paperback
• Copyright: 2002-08-15
• Publisher: Delmar Cengage Learning

Summary

This handbook offers a thorough overview of nursing documentation, and its importance, within the context of the nursing process. Users learn the principles of effective documentation and methods of documenting and examine trends relevant to this aspect of nursing care. Example forms are included to provide readers with hands-on experience with the documentation format.

Table of Contents

Preface	ix
Organization	ix
Features	x
Acknowledgments	xi
About the Author	xi
Reviewers	xii
UNIT 1 NURSING PROCESS	1	(70)
Nursing Process	3	(12)
Introduction	3	(1)
Historical Perspective	4	(1)
Overview of the Nursing Process	5	(1)
The Nursing Process and Critical Thinking	6	(3)
The Nursing Process and Problem Solving	9	(1)
The Nursing Process and Decision Making	9	(1)
The Nursing Process and Holistic Care	10	(5)
Assessment	15	(16)
Introduction	15	(1)
Purpose of Assessment	16	(1)
Database	16	(1)
Collecting Data	16	(7)
Types of Assessment	16	(1)
Comprehensive Assessment	17	(1)
Focused Assessment	17	(1)
Ongoing Assessment	17	(2)
Sources of Data	19	(1)
Types of Data	20	(3)
Validating the Data	23	(1)
Organizing the Data	23	(3)
Hierarchy of Needs	24	(1)
Body Systems Model	24	(1)
Functional Health Patterns	25	(1)
Theory of Self-Care	25	(1)
Interpreting the Data	26	(1)
Documenting the Data	26	(5)
Diagnosis	31	(10)
Introduction	31	(3)
Components of a Nursing Diagnosis	34	(1)
Two-Part Statement	34	(1)
Three-Part Statement	34	(1)
Writing the Nursing Diagnosis Statement	35	(1)
Types of Nursing Diagnoses	35	(2)
Collaborative Problems	37	(4)
Planning and Outcome Identification	41	(14)
Introduction	41	(1)
Planning	42	(1)
Prioritizing the Nursing Diagnoses	42	(1)
Identifying Outcomes	43	(2)
Goals	43	(1)
Expected Outcomes	44	(1)
Developing Specific Nursing Interventions	45	(2)
Categories of Nursing Interventions	47	(1)
Recording the Nursing Care Plan	47	(8)
Implementation	55	(8)
Introduction	55	(1)
Requirements for Effective Implementation	56	(1)
Types of Nursing Interventions	57	(1)
Documenting and Reporting Interventions	58	(5)
Evaluation	63	(8)
Introduction	63	(1)
Evaluation	63	(3)
Nursing Audit	66	(2)
Case Study	68	(3)
UNIT 2 DOCUMENTATION	71	(108)
Documentation as Communication	73	(20)
Introduction	73	(1)
Documentation Defined	73	(1)
Purposes of Health Care Documentation	74	(19)
Communication	75	(1)
Education	75	(4)
Research	79	(1)
Legal and Practice Standards	80	(1)
Informed Consent	80	(2)
Advance Directives	82	(1)
State Nursing Practice Acts	83	(1)
Joint Commission on Accreditation of Healthcare Organizations	84	(2)
Reimbursement	86	(7)
Principles of Effective Documentation	93	(16)
Introduction	93	(1)
Follow the Nursing Process	93	(2)
Elements of Effective Documentation	95	(7)
Accurate, Complete, and Objective	96	(1)
Date and Time	96	(2)
Use Appropriate Forms	98	(1)
Identify the Client	98	(1)
Write in Ink	98	(1)
Use Standard Abbreviations	99	(1)
Spell Correctly	99	(1)
Write Legibly	99	(1)
Correct Errors Properly	100	(1)
Write on Every Line	100	(1)
Chart Omissions	100	(1)
Sign Each Entry	101	(1)
Documenting a Medication Error	102	(7)
Medication Incident Report	103	(6)
Methods of Documentation	109	(20)
Introduction	109	(1)
Narrative Charting	110	(1)
Source-Oriented Charting	111	(1)
Problem-Oriented Charting	111	(1)
PIE Charting	112	(1)
Focus Charting	112	(2)
Charting by Exception	114	(1)
Computerized Charting	115	(2)
Point-of-Care Charting	117	(1)
Critical Pathway	118	(11)
Forms for Recording Data	129	(16)
Introduction	129	(1)
Kardex	129	(2)
Flow Sheets	131	(3)
Nurses' Progress Notes	134	(2)
Discharge Summary	136	(9)
Trends in Documentation	145	(10)
Introduction	145	(1)
Nursing Minimum Data Set	146	(1)
Nursing Diagnoses	146	(1)
Nursing Interventions Classification	147	(2)
Nursing Outcomes Classification	149	(6)
Reporting	155	(24)
Introduction	155	(2)
Summary Reports	157	(1)
Walking Rounds	157	(2)
Telephone Reports and Orders	159	(1)
Incident Reports	160	(7)
APPENDICES
Appendix A NANDA Nursing Diagnoses 2001-2002	167	(4)
Appendix B Abbreviations, Acronyms, and Symbols	171	(4)
Appendix C Answers to Review Questions	175	(4)
Glossary	179	(6)
Index	185