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.Carpenito-Moyet, L.J. Understanding the Nursing Processa€”Concept Mapping and Care Planning for Students. Philadelphia: ... Dochterman, J.M., and Bulechek , G.M. Nursing Interventions Classification (NIC), 4th ed. St. Louis: Mosby, 2004.

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


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