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

by Unknown
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  • Format: Paperback
  • Copyright: 2001-07-03
  • Publisher: Spring House
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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 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)
A Documentation systems
B JCAHO nursing care and documentation standards
C Commonly accepted abbreviations
D Commonly accepted symbols
E NANDA Taxonomy II codes
Selected references 467(1)
Index 468

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