Documentation in Action.
Title:
Documentation in Action.
Author:
Springhouse.
ISBN:
9781469885872
Personal Author:
Physical Description:
1 online resource (416 pages)
Contents:
Documentation in Action -- Contents -- Contributors and consultants -- Foreword -- Documenting everyday events -- Documenting from admission to discharge -- Legal and ethical implications of documentation -- Legally perilous documentation -- Computerized patient records -- Documentation in acute care -- Documentation in selected clinical specialty areas -- Documentation in ambulatory care -- Documentation in long-term care -- Documentation in home health care -- Comparing documentation systems -- Selected references -- Index.
Abstract:
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.
Local Note:
Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, 2017. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries.
Genre:
Electronic Access:
Click to View