Surefire Documentation: How, What, and When Nurses Need To Document

Softbound: 384 pages
ISBN 0323034349
978-0323034340
CV Mosby
February 2006
(click button below for the very best currently available price for this important resource)

Mosbys Surefire Documentation uses clear concise reading style to give specific, practical advice of how, what, and when to document over 100 of the most common and most important situations nurses face.

This book is conveniently divided into 3 sections: Caring for Patients; Dealing with Special Situations; and Practicing Yourself Legally - with every entry explaining exactly what to consider and document, so that nurses can ensure quality patient care, continuity of care, and legal protection.

Nurse Executives: You may wish to make a copy of this guide available in each nursing office or station.

This edition is thoroughly updated to reflect the latest HIPAA and JCAHO recommendations and standards as well as the most current legal tips and advice. A special emphasis has been placed on the evolving role and means of electronic documentation in the clinical setting.

Provides practical advice that is useful for everyday documentation challenges.
Explains how to document unusual or difficult developments or events.
Case histories that illustrate key legal points
Tips to help nurses streamline documentation without sacrificing accuracy
Guidance for documenting unusual or difficult developments or events
Clear, concise explanations of complex legal terms and concepts
Advice on how and why to document for a variety of documentation systems
Charting Checklists identify essential points to record for a particular situation
Legal Briefs explain legal terms, such as a living will, or give practical advice for avoiding legal pitfalls
Case Law Close-Ups describe specific court cases, explain the court's ruling, and point out the nursing implications
Tips and Advice help the nurse solve documentation problems, such as correcting a mistaken entry, and give advice on recording data in complex situations
Did you know? sections present interesting, practical, or little-known points related to a specific topic
Includes tips and advice to help streamline documentation! without sacrificing accuracy.
Offers expert advice on everyday legal issues related to documentation to help the nurse legally protect herself and the employer.
Provides explanations of legal terms in easy-to-understand language.
Shows and explains how to document safely and correctly to ensure quality and continuity of care.
Uses case histories to illustrate key legal points.
Explains how and why to document in a variety of documentation systems.

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