Complete Guide to Documentation (LWW, Complete Guide to Documentation) [Paperback]
Author: See details nearcostbooks Fulfilled by Amazon Sign in to turn on 1-Click ordering | Language: English | ISBN: 1582555567 | Format: PDF, EPUB
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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.
- Series: LWW, Complete Guide to Documentation
- Paperback: 448 pages
- Publisher: LWW; Second edition (May 11, 2007)
- Language: English
- ISBN-10: 1582555567
- ISBN-13: 978-1582555560
- Product Dimensions: 0.9 x 7.2 x 9 inches
- Shipping Weight: 1.4 pounds (View shipping rates and policies)
- Amazon Best Sellers Rank: #279,672 in Books (See Top 100 in Books)
- #31 in Books > Medical Books > Medical Informatics
I'm always drawn to books that either teach the basic principles, or build on the basic principles. This one does both.
Some of the chapters are ho-hum for the experienced nurse. As a maternal-child nurse with 25+ years of experience, I probably could have written that section. Yet, content on frequency of documentation for the laboring patient, while not "new", prompts the reader to remember that frequency of documentation is related to the complexity of the labor and the medications given. A glaring omission in that section was documentation for the postpartum mother after the first hour. Most notably, the standard 8-point check--which seems to be nowhere in the nurse's skill set these days--should have been included. Overall, every chapter contained some tidbit of information that I was unaware of.
Other chapters are great for the nurse who needs an update, or even just guidance for charting in a new facility or a different specialty. When I was in school SOAP notes were the big thing. This book gave several formats for charting e.g., PIE, AIR, POMR, and several others. These formats were also included on a table that described the features of each. There was also mention of several issues that simply weren't issues when I went to school, e.g., documenting abuse, faxing orders, and so forth.
For the nurse who doesn't know much about computerized documentation, this is a great resource. Again, it sticks with the basic principles of how-to, but tackles questions like advantages of and disadvantages of computerized charting. (Let's face it, folks, we're all going to need to know how to do computerized patient records, sooner or later!
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