Long Term Care Documentation

Among the issues confronting America is long-term care for frail, older persons and others with chronic conditions and functional limitations that limit their ability to care for themselves. Improving the Quality of Long-Term Care takes a comprehensive look at the quality of care and quality of life in long-term care, including nursing homes, home health agencies, residential care facilities, family members and a variety of others. This book describes the current state of long-term care, identifying problem areas and offering recommendations for federal and state policymakers. Who uses long-term care? How have the characteristics of this population changed over time? What paths do people follow in long term care? The committee provides the latest information on these and other key questions. This book explores strengths and limitations of available data and research literature especially for settings other than nursing homes, on methods to measure, oversee, and improve the quality of long-term care. The committee makes recommendations on setting and enforcing standards of care, strengthening the caregiving workforce, reimbursement issues, and expanding the knowledge base to guide organizational and individual caregivers in improving the quality of care.

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.

From pain assessment methods to intravenous drip calculations, the Long-Term Care Nursing Desk Reference offers long-term care nurses virtually every tool they need to provide high-quality, regulation-compliant, long-term resident care. Written by accomplished author and speaker Barbara Acello, MS, RN, this authoritative reference is jam-packed with practical, need-to-know patient care information, essential policies and procedures, and vital regulatory and safety requirements. In short, the Long-Term Care Nursing Desk Reference is the book you and your nurses have been waiting for!

This resource is the first to include documentation guidelines and their applications in long term care complete with the new RUG regulations and the MDS 2. In clear and concise terms a method of documenting nursing care is described using a self-care emphasis on all documentation. The book is organized to allow easy access to information. Sections include those focused on basic bodily processes: breathing, eating, drinking, activity, sleep, etc. The book also includes nursing diagnoses, nursing interventions classification, and nursing outcome terms.

Part of the Springhouse Incredibly Easy! Series(TM), this Second Edition provides current information about charting in a comprehensible, clear, fun and concise manner. Three sections cover Charting Basics, Charting in Contemporary Health Care, and Special Topics. New features include expanded coverage of computerized documentation and charting specific patient care procedures, plus current JCAHO standards both in the text and appendix, chapter summaries, and a new section with case study questions and answers. Amusing graphics and cartoon characters call special attention to important information. Entertaining logos throughout the text alert the reader to critical information, Thought Pillows identify key features of documentation forms, and the glossary defines difficult or often-misunderstood terms.

"This resource will help you: Align with MDS 3.0 documentation requirements. Coordinate documentation between nurses and therapists to improve resident care. Gain the perspective of nursing or therapy to appreciate their specific approach to skilled services. Reduce your audit risk and strengthen reimbursement claims with comprehensive documentation. Prove medical necessity and need for skilled care by practicing accurate documentation"--Page 4 of cover

Clinical documentation can significantly affect a nursing home's survey results, reimbursement received, and most importantly, resident care. Yet, little formal training is given on how to complete this complicated, and often confusing, process. With so much at stake, it's critical that nurses have a resource they can turn to in order to help achieve accurate, comprehensive documentation for all residents.