Mosby's Surefire Documentation : How, What, and When Nurses Need to Document

by Mosby

• ISBN13: 9780323034340
• ISBN10: 0323034349
• Edition: 2nd
• Format: Paperback
• Copyright: 2006-01-01
• Publisher: MOSBY-YEAR BOOK INC

Summary

Mosby's Surefire Documentation, 2nd Edition offers clear, practical guidelines for how, what, and when to document for more than 100 of the most common and most important situations nurses face. Divided into 3 sections Caring for Patients, Dealing with Challenging Patient Situations, and Handling Difficult Professional Problems this essential resource details exactly what information to consider and document, to ensure quality patient care, continuity of care, and legal protection for the nurse and the institution where the nurse works. UNIQUE! Case histories that illustrate key legal points Tips to help nurses streamline documentation without sacrificing accuracy Guidance for documenting unusual or difficult developments or events Clear, concise explanations of complex legal terms and concepts Advice on how and why to document for a variety of documentation systems Charting Checklists identify essential points to record for a particular situation Legal Briefs explain legal terms, such as a living will, or give practical advice for avoiding legal pitfalls Case Law Close-Ups describe specific court cases, explain the court's ruling, and point out the nursing implications Tips and Advice help the nurse solve documentation problems, such as correcting a mistaken entry, and give advice on recording data in complex situations Did you know? sections present interesting, practical, or little-known points related to a specific topic Completely updated content throughout that reflects the latest information and guidelines affecting documentation, including HIPAA and JCAHO standards. Expanded coverage of electronic documentation and its implications for nurses. A wealth of new and expanded special features such as Charting Checklists, Legal Briefs, and Case Law Close-Ups that further illustrate important documentation and legal considerations

Table of Contents

Contributors and Consultants,	vii
Foreword,	ix
Overview of Documentation,	1	(10)
PART 1 Caring for Patients,	11	(188)
When you perform your initial patient assessment,	15	(8)
When your patient loses a peripheral pulse,	23	(5)
When your patient has chest pain,	28	(6)
When your patient has a myocardial infarction,	34	(5)
When your patient has heart failure,	39	(7)
When your patient is in shock,	46	(6)
When your patient has cardiopulmonary arrest,	52	(5)
When your patient has a new arrhythmia,	57	(6)
When your patient has hypertensive crisis,	63	(5)
When your patient has pneumonia,	68	(8)
When your patient has pneumothorax,	76	(5)
When your patient has an asthma attack,	81	(5)
When your patient has a pulmonary embolism,	86	(5)
When your patient has pulmonary edema,	91	(5)
When your patient has pulmonary tuberculosis,	96	(6)
When your patient has severe pain,	102	(7)
When your patient is confused,	109	(5)
When your patient has a seizure,	114	(6)
When your patient has a cerebrovascular accident,	120	(5)
When your patient is unresponsive,	125	(5)
When your patient aspirates a tube feeding,	130	(3)
When your patient has GI hemorrhage,	133	(7)
When your patient has hypoglycemia,	140	(3)
When your patient has hyperglycemia,	143	(4)
When your patient has anaphylaxis,	147	(3)
When your patient has a transfusion reaction,	150	(4)
When your patient has HIV infection,	154	(5)
When your patient has a pressure ulcer,	159	(7)
When your patient has an infected wound,	166	(7)
When your patient has sepsis,	173	(4)
When your patient has an adverse drug reaction,	177	(4)
When your patient has I.V. infiltration,	181	(3)
When your patient has surgery,	184	(9)
When your patient has wound dehiscence or evisceration,	193	(6)
PART 2 Dealing with Challenging Patient Situations,	199	(130)
When your patient documents her own care,	202	(2)
When your patient asks to see his medical record,	204	(4)
When your patient's medical record isn't available,	208	(4)
When your patient withholds his medical history,	212	(3)
When your patient refuses treatment,	215	(3)
When your patient is noncompliant,	218	(2)
When your patient is in police custody,	220	(5)
When your patient leaves against medical advice,	225	(3)
When your patient threatens to sue,	228	(5)
When your patient makes a sexual advance,	233	(3)
When your patient becomes hostile,	236	(3)
When your patient threatens to harm someone,	239	(5)
When your patient must be restrained,	244	(7)
When your patient is anxious,	251	(3)
When your patient threatens suicide,	254	(6)
When your patient accidentally injures himself,	260	(6)
When your patient is caught smoking,	266	(3)
When your patient has contraband,	269	(3)
When your patient tampers with medical equipment,	272	(3)
When your patient hides his drugs,	275	(3)
When your patient removes her endotracheal tube,	278	(2)
When your patient removes his chest tube,	280	(3)
When your patient speaks a different language,	283	(2)
When your patient has a hearing impairment,	285	(3)
When your patient has a vision impairment,	288	(3)
When your patient is obese,	291	(3)
When your patient can't give informed consent,	294	(5)
When your patient doesn't understand the procedure he's about to undergo,	299	(2)
When your patient's equipment fails,	301	(3)
When your patient's belongings are missing,	304	(2)
When your patient's family questions the quality of care,	306	(2)
When you suspect that your patient has been abused,	308	(3)
When your patient's visitors won't leave,	311	(2)
When your patient is seriously ill,	313	(3)
When your patient asks you to witness her last will and testament,	316	(4)
When a patient dies,	320	(3)
When your patient donates an organ,	323	(6)
PART 3 Handling Difficult Professional Problems,	329	(66)
When a physician or colleague illegally alters the medical record,	332	(3)
When a colleague criticizes your care in the medical record,	335	(2)
When you find an inappropriate comment in the medical record,	337	(1)
When a physician asks to remove a medical record from the facility,	338	(4)
How to handle a physician's questionable order,	342	(2)
When you take a telephone or verbal order,	344	(3)
When a physician's order is illegible,	347	(2)
When a colleague asks you to document her care,	349	(2)
When a coworker gives your patient drugs in your absence,	351	(1)
When you suspect that a colleague is negligent,	352	(1)
How to document care given by unlicensed assistive personnel,	353	(3)
When you're asked to countersign a colleague's notes,	356	(2)
When you must work on an understaffed unit,	358	(2)
When your patient or her family asks you for medical advice,	360	(3)
When the physician and family decide to terminate the patient's life support,	363	(3)
When the physician writes a "do not resuscitate" order,	366	(3)
When you withhold a prescribed drug or other patient care,	369	(1)
When someone asks to photograph or videotape your patient,	370	(2)
When a member of the media asks for patient information,	372	(2)
When your patient is transferred or discharged,	374	(3)
How to make a late entry,	377	(4)
How to use abbreviations safely,	381	(2)
How to complete an incident report,	383	(3)
How to avoid the pitfalls of computer documentation,	386	(3)
How to protect your patient's privacy when faxing medical records,	389	(3)
How to protect patient confidentiality when using the Internet,	392	(3)
Index,	395