Publisher description for Documentation.


Bibliographic record and links to related information available from the Library of Congress catalog


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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.




Library of Congress subject headings for this publication:
Nursing records -- Handbooks, manuals, etc.
Nursing -- Documentation -- Handbooks, manuals, etc.
Nursing Records -- Handbooks.
Documentation -- methods -- Handbooks.
Forms and Records Control -- methods -- Handbooks.
Specialties, Nursing -- organization & administration -- Handbooks.