[PDF] Nursing Documentation Handbook eBook

Author : Debra Sullivan
Publisher : F.A. Davis
Page : 301 pages
File Size : 49,86 MB
Release : 2011-12-22
Category : Medical
ISBN : 0803629974

GET BOOK

Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

Author : Kate Stout
Publisher : Lippincott Williams & Wilkins
Page : 487 pages
File Size : 30,60 MB
Release : 2018-06-05
Category : Medical
ISBN : 1496394747

GET BOOK

Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more. Whether you are a nursing student or a new or experienced nurse, this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely, accurate, and watertight. Let the experts walk you through up-to-date best practices for nursing documentation, with: NEW and updated, fully illustrated content in quick-read, bulleted format NEWdiscussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices Easy-to-read, easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations, while addressing the different styles of charting Outlines the Do's and Don’ts of charting – a common sense approach that addresses a wide range of topics, including: Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation Documenting the patient’s health history and physical examination The Joint Commission standards for assessment Patient rights and safety Care plan guidelines Enhancing documentation Avoiding legal problems Documenting procedures Documentation practices in a variety of settings—acute care, home healthcare, and long-term care Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior Special features include: Just the facts – a quick summary of each chapter’s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans “Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.

Author :
Publisher : Springhouse Corporation
Page : 516 pages
File Size : 19,34 MB
Release : 2011
Category : Medical
ISBN :

GET BOOK

Chart Smart: the A-to-Z Guide to Better Nursing Documentation tells nurses exactly what to document in virtually every type of situation they may encounter on the job, no matter where they practice--hospital, medical office, outpatient, rehabilitation facility, long-term care facility, or home. This portable handbook has nearly 300 entries that cover documentation required for common diseases, major emergencies, complex procedures, and difficult situations involving patients, families, other health care team members, and supervisors. In addition to patient care, this book also covers documenta

Author :
Publisher : Lippincott Williams & Wilkins
Page : 424 pages
File Size : 14,84 MB
Release : 2009
Category : Medical
ISBN : 9780781791946

GET BOOK

Provides information on documentation issues, including electronic medical records, legal and ethical implications, and documentation in acute cases, along with a variety of charting examples.

Author : Cherie Rebar
Publisher : F.A. Davis
Page : 203 pages
File Size : 28,86 MB
Release : 2009-04-10
Category : Medical
ISBN : 0803623364

GET BOOK

The perfect guide to charting! The popular Davis’s Notes format makes sure that you always have the information you need close at hand to ensure your documentation is not only complete and thorough, but also meets the highest ethical and legal standards. You’ll even find coverage of the nuances that are relevant to various specialties, including pediatric, OB/GYN, psychiatric, and outpatient nursing.

Author : T. M. Marrelli
Publisher : Mosby Elsevier Health Science
Page : 300 pages
File Size : 35,41 MB
Release : 1992
Category : Nursing records
ISBN : 9780801631207

GET BOOK

This practical guide to 50 frequently encountered problems, their diagnosis and management, includes documentation which will fulfill legal, quality assurance and reimbursement requirements. Alphabetically organized, the book helps identify interventions, data, and outcomes appropriate for specific patients.

Author : Karen Stuart Gelety
Publisher :
Page : 50 pages
File Size : 47,20 MB
Release : 2010-11-01
Category : Nursing records
ISBN : 9780975999868

GET BOOK

Ever wonder what to put in a nursing note? This pocket sized guide provides you with over a hundred templates for written and verbal comminication in nursing to help you.

Author : Theresa Capriotti
Publisher : Lippincott Williams & Wilkins
Page : 499 pages
File Size : 27,82 MB
Release : 2019-06-26
Category : Medical
ISBN : 1975120744

GET BOOK

Feeling unsure about documenting patient care? Learn to document with skill and ease, with the freshly updated Document Smart, 4th Edition. This unique, easy-to-use resource is a must-have for every student and new nurse, offering more than 300 alpha-organized topics that demonstrate the latest nursing, medical and government best practices for documenting a wide variety of patient conditions and scenarios. Whether you are assessing data, creating effective patient goals, choosing optimal interventions or evaluating treatment, this is your road map to documentation confidence and clarity.