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Complete Guide to Documentation
Roberto Patarca-Montero, MD, PhD,
HCLD Director, E.M. Papper Laboratory of Clinical Immunology, University of Miami School of Medicine, Miami, Florida
16 CPEU or CE hours
Course: $128
Includes book & CE exam
CE exam only: $88
"Download on demand" available
Roberto Patarca-Montero, MD, PhD,
HCLD Director, E.M. Papper Laboratory of Clinical Immunology, University of Miami School of Medicine, Miami, Florida
16 CPEU or CE hours
Course: $128
Includes book & CE exam
CE exam only: $88
"Download on demand" available
Description
Be confident that you’re charting clearly and completely. The second edition of Complete Guide to Documentation provides the charting tools you need for total coverage, regardless of practice setting, clinical specialty, and documentation format. Includes charting in acute, long-term, home health, and ambulatory practice areas Covers documentation for critical care, emergency, maternal-neonatal pediatric, psychiatric, and surgical nursing specialties Compares current documentation formats and systems Features more than 100 sample forms, correctly filled out Up-to-the-minute coverage Legally perilous charting practices, ethical dilemmas, and tips for charting defensively An all-new section providing guidelines for electronic documentation The latest Joint Commission standards, which your documentation must meet to maintain accreditation
Level: Advanced
ISBN: 1582555567
ISBN-13: 9781582555560
Format: Paperback, 448pp
Publisher: Lippincott Williams & Wilkins
Edition Description: Revised
Edition Number: 2
Pub date: 2007
Content
Contributors and consultants
Foreword
Part I. Fundamentals
Chapter 1. Nursing documentation and the medical record
Chapter 2. Legal and ethical implications of documentation
Chapter 3. Performance improvement and reimbursement
Chapter 4. Documentation systems
Chapter 5. Documentation of the nursing process
Part II. Documentation in Practice Settings
Chapter 6. Documentation in acute care
Chapter 7. Documentation in long-term care
Chapter 8. Documentation in home health care
Chapter 9. Documentation in ambulatory care
Part III. Documentation in Action
Chapter 10. Documentation of everyday events
Chapter 11. Documentation of selected clinical specialties
Chapter 12. Legally perilous charting practices
Part IV. Electronic Documentation
Chapter 13. Electronic medical records
Chapter 14. Electronic nursing documentation
NANDA-I nursing diagnoses by domain
The Joint Commission nursing care and documentation standards
Outcomes and interventions for common nursing diagnoses
Index
Dietetic professionals
CPE Level: 3
Suggested Commission on Dietetic Registration Learning Need Codes: It is the sole responsibility of the dietetic professional to determine the learning need code met by a course. numedix.com provides the following "suggested" codes, but the professional can deviate from them if they feel another need is met.
1040 Cultural sensitivity
1060 Foreign language, cultures
1070 Leadership, critical and strategic thinking
1090 Media skills
1140 Written communication skills, publishing
3000 Nutrition assessment
4000 Wellness and public health
4030 Dietary guidelines, DRIs, Food Guide Pyramid, food labeling
5390 Care planning, documentation and evaluation
5400 Case management
6000 Education, training and counseling
6010 Behavior change theories, techniques
6020 Counseling, therapy and facilitation skills
6030 Education theories and techniques for adults
6040 Education theories and techniques for children and adolescents
6050 Instructional materials development
7040 Consultation
7100 Institution/regulatory policies and procedures, HCFA, OBRA, JACHO, NCQA, OSHA
Be confident that you’re charting clearly and completely. The second edition of Complete Guide to Documentation provides the charting tools you need for total coverage, regardless of practice setting, clinical specialty, and documentation format. Includes charting in acute, long-term, home health, and ambulatory practice areas Covers documentation for critical care, emergency, maternal-neonatal pediatric, psychiatric, and surgical nursing specialties Compares current documentation formats and systems Features more than 100 sample forms, correctly filled out Up-to-the-minute coverage Legally perilous charting practices, ethical dilemmas, and tips for charting defensively An all-new section providing guidelines for electronic documentation The latest Joint Commission standards, which your documentation must meet to maintain accreditation
Level: Advanced
ISBN: 1582555567
ISBN-13: 9781582555560
Format: Paperback, 448pp
Publisher: Lippincott Williams & Wilkins
Edition Description: Revised
Edition Number: 2
Pub date: 2007
Content
Contributors and consultants
Foreword
Part I. Fundamentals
Chapter 1. Nursing documentation and the medical record
Chapter 2. Legal and ethical implications of documentation
Chapter 3. Performance improvement and reimbursement
Chapter 4. Documentation systems
Chapter 5. Documentation of the nursing process
Part II. Documentation in Practice Settings
Chapter 6. Documentation in acute care
Chapter 7. Documentation in long-term care
Chapter 8. Documentation in home health care
Chapter 9. Documentation in ambulatory care
Part III. Documentation in Action
Chapter 10. Documentation of everyday events
Chapter 11. Documentation of selected clinical specialties
Chapter 12. Legally perilous charting practices
Part IV. Electronic Documentation
Chapter 13. Electronic medical records
Chapter 14. Electronic nursing documentation
NANDA-I nursing diagnoses by domain
The Joint Commission nursing care and documentation standards
Outcomes and interventions for common nursing diagnoses
Index
Dietetic professionals
CPE Level: 3
Suggested Commission on Dietetic Registration Learning Need Codes: It is the sole responsibility of the dietetic professional to determine the learning need code met by a course. numedix.com provides the following "suggested" codes, but the professional can deviate from them if they feel another need is met.
1040 Cultural sensitivity
1060 Foreign language, cultures
1070 Leadership, critical and strategic thinking
1090 Media skills
1140 Written communication skills, publishing
3000 Nutrition assessment
4000 Wellness and public health
4030 Dietary guidelines, DRIs, Food Guide Pyramid, food labeling
5390 Care planning, documentation and evaluation
5400 Case management
6000 Education, training and counseling
6010 Behavior change theories, techniques
6020 Counseling, therapy and facilitation skills
6030 Education theories and techniques for adults
6040 Education theories and techniques for children and adolescents
6050 Instructional materials development
7040 Consultation
7100 Institution/regulatory policies and procedures, HCFA, OBRA, JACHO, NCQA, OSHA
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