Nursing Documentation Handbook
Author: T. M. Marrelli
Publisher:
Published: 2000
Total Pages: 0
ISBN-13:
DOWNLOAD EBOOKRead and Download eBook Full
Author: T. M. Marrelli
Publisher:
Published: 2000
Total Pages: 0
ISBN-13:
DOWNLOAD EBOOKAuthor: Debra Sullivan
Publisher: F.A. Davis
Published: 2011-12-22
Total Pages: 301
ISBN-13: 0803629974
DOWNLOAD EBOOKDevelop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.
Author: Kate Stout
Publisher: Lippincott Williams & Wilkins
Published: 2018-06-05
Total Pages: 487
ISBN-13: 1496394747
DOWNLOAD EBOOKPublisher'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.
Author: Tina M. Marrelli
Publisher:
Published: 1992
Total Pages: 300
ISBN-13: 9780801689680
DOWNLOAD EBOOKAuthor:
Publisher: Lippincott Williams & Wilkins
Published: 2009
Total Pages: 424
ISBN-13: 9780781791946
DOWNLOAD EBOOKProvides information on documentation issues, including electronic medical records, legal and ethical implications, and documentation in acute cases, along with a variety of charting examples.
Author:
Publisher: Springhouse Corporation
Published: 2011
Total Pages: 516
ISBN-13:
DOWNLOAD EBOOKChart Smart: the A-to-Z Guide to Better Nursing Documentation tells nurses exactly what to document in virtually every type of situation they may encounter on the job, no matter where they practice--hospital, medical office, outpatient, rehabilitation facility, long-term care facility, or home. This portable handbook has nearly 300 entries that cover documentation required for common diseases, major emergencies, complex procedures, and difficult situations involving patients, families, other health care team members, and supervisors. In addition to patient care, this book also covers documenta
Author: T. M. Marrelli
Publisher: Mosby Elsevier Health Science
Published: 1992
Total Pages: 300
ISBN-13: 9780801631207
DOWNLOAD EBOOKThis practical guide to 50 frequently encountered problems, their diagnosis and management, includes documentation which will fulfill legal, quality assurance and reimbursement requirements. Alphabetically organized, the book helps identify interventions, data, and outcomes appropriate for specific patients.
Author: Karen Stuart Gelety
Publisher:
Published: 2010-11-01
Total Pages: 50
ISBN-13: 9780975999868
DOWNLOAD EBOOKEver wonder what to put in a nursing note? This pocket sized guide provides you with over a hundred templates for written and verbal comminication in nursing to help you.
Author: Cherie Rebar
Publisher:
Published: 2009
Total Pages: 0
ISBN-13: 9780803620926
DOWNLOAD EBOOKReviews the terminology for written communications with physicians and staff. Describe the types of documentation, including SOAP notes and DART charts. Details the documentation of history taking, including medical, social, and family history, physical assessments, and systems. Covers the documentation of nursing skills and procedures as well as medication administration. Addresses the documentation required in specialized fields such as OB/GYN, pediatrics, psychiatric, and outpatient nursing. Includes how-tos for template, electronic, and other forms of charting.
Author: Kathy Ferrell
Publisher: Lippincott Williams & Wilkins
Published: 2015-08-31
Total Pages: 360
ISBN-13: 1496302613
DOWNLOAD EBOOKAn authoritative guide to the legal and ethical issues faced daily by nurses, this handbook includes real-life examples and information from hundreds of court cases. It covers the full range of contemporary concerns, including computer documentation, workplace violence and harassment, needlesticks, telephone triage, pain management, prescribing, privacy, and confidentiality. An entire chapter explains step-by-step what to expect in a malpractice lawsuit.