Documentation in action.

Includes bibliographical references and index.

Table of Contents
Contributors and consultants xxx
Foreword xxx
Chapter 1
Documenting everyday events xxx
Chapter 2
Documenting from admission to discharge xxx
Chapter 3
Legal and ethical implications of documentation
xxx
Chapter 4
Legally perilous documentation xxx
Chapter 5
Computerized patient records xxx
Chapter 6
Documentation in acute care xxx
Chapter 7
Documentation in selected clinical specialty areas
xxx
Chapter 8
Documentation in ambulatory care xxx
Chapter 9
Documentation in long-term care xxx
Chapter 10
Documentation in home health care xxx
Comparing documentation systems xxx
NANDA nursing diagnoses xxx
Selected references xxx
Index xxx

Designed for rapid on-the-job reference, Documentation in Action offers comprehensive, authoritative, practice-oriented, up-to-the-minute guidelines for documenting every situation in every nursing practice setting and important nursing specialties. Need-to-know information is presented in bulleted lists, charts, flow sheets, sidebars, and boxes, with icons and illustrative filled-in samples.



Coverage includes documentation for care of patients with various diseases, complications, emergencies, complex procedures, and difficulties involving patients, families, and other health care professionals. Suggestions are given for avoiding legal pitfalls involving telephone orders, medication reactions, patients who refuse care, and much more. A section addresses computerized documentation, HIPAA confidentiality rules, use of PDAs, nursing informatics, and electronic innovations that will soon be universal.