Mosbys Surefire Documentation

Offering clear, practical guidelines for how, what, and when to document for more than 100 of the most common and most important situations nurses face, this essential resource details exactly what information to consider and document, to ensure quality patient care, continuity of care, and legal protection for the nurse and the institution where the nurse works.

Provides information on documentation issues, including electronic medical records, legal and ethical implications, and documentation in acute cases, along with a variety of charting examples.

Ever 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.

Nurses are now commonly cited or implicated in medical malpractice cases.

This informative title provides nurses with specific, practical advice on documenting a wide range of situations from caring for a patient with a myocardial infarction to witnessing a patient sign his will. In clear, concise language, the book gives detailed explanations of how, what, and when to document in nearly 100 of the most common, most important situations nurses face in practice. Each entry tells exactly what to consider and what to document so that the nurse can ensure quality patient care, continuity of care, and legal protection for the nurse and the institution. * Covers nearly 100 important nursing situations. * Provides clinically and legally sound advice. * Explains exactly what to do--and what not to do--for maximum protection for yourself and your institution.

Publisher'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.

AACN Procedure Manual for Critical Care offers comprehensive coverage of procedures unique to the critical care environment. This edition is thoroughly revised, updated, and expanded to reflect the current state of critical care nursing practice. Information is presented in a highly illustrated step-by-step format with supporting rationales for each step of every procedure. This resource also emphasizes evidence-based practice and provides complete coverage of the latest clinical studies. Each procedure is organized in a consistent, step-by-step format with categories that include: prerequisite nursing knowledge, equipment, patient and family education, patient assessment and preparation, procedure, expected outcomes, unexpected outcomes, patient monitoring and care, and documentation. Each procedure is supported by research-based data. Advanced practice procedures are noted with a special AP icon indicating that these procedures should be done only by qualified personnel. 19 new procedures discuss topics such as combitube insertion and removal, transesophageal echocardiography, and patient controlled analgesia. A new Quick Tips feature - located in the Special Considerations column for quick reference - highlights key words and key concepts for each procedure. A new web-enhanced feature at the beginning and end of each procedure directs readers to online supplement materials such as additional art and photographs. Web links connect users to hundreds of continually updated web sites that contain information relevant to critical care nursing practice. 200 new line drawings clearly illustrate important techniques and bring key procedures to life.