Looking for a way to invigorate your technical writing team and grow that expertise to include developers, designers, and writers of all backgrounds? When you treat docs like code, you multiply everyone's efforts and streamline processes through collaboration, automation, and innovation. Second edition now available with updates and more information about version control for documents and continuous publishing.
This is a comprehensive textbook for the documentation course required in all Physical Therapy programs. The textbook incorporates current APTA terminology and covers every aspect of documentation including reimbursement and billing, coding, legal issues, PT and PTA communication, as well as utilization review and quality assurance. (Midwest).
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.
This full-color handbook is a quick-reference guide to all aspects of documentation for every nursing care situation. It covers current documentation systems and formats, including computerized documentation, and features scores of sample filled-in forms and in-text narrative notes illustrating everything from everyday occurrences to emergency situations. Coverage includes timesaving strategies for admission-to-discharge documentation in acute, outpatient, rehabilitation, long-term, and home care environments and special documentation practices for selected clinical specialties: critical care, emergency, perioperative, maternal-neonatal, and psychiatric. The book includes advice on legal safeguards, dangerous abbreviations, and compliance with HIPAA guidelines and JCAHO requirements.
This is the only book in existence that discusses the process of documenting an investigation from start to finish. It presents just about everything an investigator needs to know regarding how to document an investigation. The first chapter discusses the five primary principles of investigative documentation: taking comprehensive notes; documenting every effort to contact witnesses and all surveillance; preparing reports whenever there is any possibility of needing to testify; taking verbatim statements from hostile witnesses and declarations from friendly witnesses; and providing all case documents to the client or maintaining a document retention plan. The second chapter details the numerous misconceptions pertaining to investigative documentation. This chapter sets the stage for the remaining chapters on note-taking, running resumes, reports, statements, and documentation retention. Each chapter is broken down into four or five sections that approximate the methods used to complete that particular documentary endeavor. The book also contains an exhaustive appendix that many investigators will find to be very useful, including: one that lists hundreds of abbreviations that investigators may find helpful when taking notes; sample reports that readers may use as templates for generating their own reports; an alphabetic stylebook that is based on styles used by the media and federal law enforcement agencies that provides a quick tool for properly referencing abbreviations, names, capitalization and numerals, among other topics; and several sample statements and declarations to show what these documents, when completed, are supposed to look like. This is an advanced book for people who already have the necessary skills to do an investigation. By following the principles outlined in this book, investigators will see the quality of their investigations improve markedly and ultimately be more successful.
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.
Yoost and Crawford's Fundamentals of Nursing is back for a second-edition encore! The text that made its name by focusing on simple language and active learning continues its focus on helping you truly understand, apply, and retain important nursing information and concepts. Using a warm and conversational style, this new second edition guides you towards a basic understanding of the nursing profession and then logically progresses through the nursing process and into the safe and systematic methods of applying care. Each chapter features realistic and complex case studies and critical thinking exercises woven throughout the content to help you continually apply what you've learned to actual patient care. A conceptual care mapping approach — created by Yoost and Crawford themselves — further your ability to make clinical judgments and synthesize knowledge as you develop plans of care after analyzing and clustering related patient assessment data. All of this paired with a wealth of student-friendly learning features and clinically-focused content offers up a fundamentally different — and effective — way for you to easily master the fundamentals of nursing. - UNIQUE! Warm, friendly writing style slows down the pace of information to give readers time to critically think and master all fundamental concepts and skills. - UNIQUE! Building block approach groups topics and concepts together thematically, in the order needed for readers to build their knowledge. - UNIQUE! Objective-driven approach presents clearly defined, numbered objectives that coordinate with all content and then wrap up with Objective Summaries. - UNIQUE! Active learning activities are incorporated throughout every chapter to help readers learn to apply chapter content to broader nursing concepts and realistic patient scenarios. - UNIQUE! Conceptual care mapping is taught and used throughout the text in conjunction with the Conceptual Care Map Creator. - UNIQUE! Emphasis on QSEN reinforces the Quality and Safety Education for Nurses competencies, including: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. - Special feature boxes cover the areas of: diversity consideration, evidence-based practice, informatics, patient education, healthy literacy, health assessment questions, interprofessional collaboration and delegation, ethical and legal practice, home care considerations, safe practice alerts, QSEN, critical thinking exercises, and nursing care guidelines. - NEW! Interprofessional collaboration and delegation content appears throughout the text along with new IPE activities that are integrated into the Evolve resources. - NEW & UNIQUE! Review and exam questions tied to learning objectives use a building-block style approach that starts at lower Bloom's taxonomy levels in early chapters and builds to more complex levels as readers acquire more knowledge. - NEW! Emphasis on assignment and delegation covers the differences between them and how and when they're appropriate for an RN. - NEW! Content on complementary therapies has been integrated throughout the text to reflect the changes to the NCLEX exam. - NEW! Additional information has been added in the areas of HCAHPS, Health Literacy, Patient Education, Drugs of Abuse, Zika, Ebola, and more.
Thoroughly updated for its Fourth Edition, this award-winning handbook gives mental health professionals authoritative guidance on how the law affects their clinical practice. Each chapter presents case examples of legal issues that arise in practice, clearly explains the governing legal rules, their rationale, and their clinical impact, and offers concrete action guides to navigating clinico-legal dilemmas. This edition addresses crucial recent developments including new federal rules protecting patients' privacy, regulations minimizing use of seclusion and restraint, liability risks associated with newer psychiatric medications, malpractice risks in forensic psychiatry, and new structured assessment tools for violence risk, suicidality, and decisional capacity.
