Complete Guide to Documentation

Complete Guide to Documentation

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Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management. Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.Among the areas that youa#39;ll assess are cognitive function; communication and hearing patterns (note if a hearing aid is present); vision (note if visual ... The Joint Commissiona#39;s 2007 National Patient Safety Goals require facilities to implement a standardized approach to aquot;hand-offaquot; communications, ... Review all treatments and instructions with the patient or responsible caregiver and document their understanding. ... (See Transfer and personal belongings form, pages 203 and 204.)anbsp;...

Title:Complete Guide to Documentation
Author:Lippincott Williams & Wilkins
Publisher:Lippincott Williams & Wilkins - 2008


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