Mosby

Mosby's Surefire Documentation

How, What, and When Nurses Need To Document

Mosby's Surefire Documentation, 2nd Edition offers clear, practical guidelines for how, what, and when to document for more than 100 of the most common and most important situations nurses face. Divided into 3 sections — Caring for Patients, Dealing with Challenging Patient Situations, and Handling Difficult Professional Problems — 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.

Paperback, 432 Pages

Published: January 2006

Imprint: Mosby

ISBN: 978-0-323-03434-0

Contents

  • Part 1: Caring for Patients
    When you perform your initial patient assessment
    When your patient loses a peripheral pulse
    When your patient has chest pain
    When your patient has a myocardial infarction
    When your patient has heart failure
    When your patient is in shock
    When your patient has cardiopulmonary arrest
    When your patient has a new arrhythmia-NEW!
    When your patient has hypertensive crisis- NEW!
    When your patient has pneumonia
    When your patient has pneumothorax- NEW!
    When your patient has an asthma attack
    When your patient has a pulmonary embolism
    When your patient has pulmonary edema
    When your patient has pulmonary tuberculosis
    When your patient has severe pain
    When your patient is confused
    When your patient has a seizure
    When your patient has a cerebrovascular accident
    When your patient is unresponsive
    When your patient aspirates a tube feeding
    When your patient has GI hemorrhage- NEW!
    When your patient has hypoglycemia
    When your patient has hyperglycemia
    When your patient has anaphylaxis
    When your patient has a transfusion reaction- NEW!
    When your patient has HIV infection
    When your patient has a pressure ulcer
    When your patient has an infected wound
    When your patient has sepsis- NEW!
    When your patient has an adverse drug reaction
    When your patient has I.V. infiltration
    When your patient has surgery
    When your patient has wound dehiscence or evisceration- NEW!

    Part 2: Dealing with Challenging Patient Situations
    When your patient documents her own care
    When your patient asks to see his medical record
    When your patient's medical record isn't available
    When your patient withholds his medical history
    When your patient refuses treatment
    When your patient is noncompliant
    When your patient is in police custody
    When your patient leaves against medical advice
    When your patient threatens to sue
    When your patient makes a sexual advance
    When your patient becomes hostile
    When your patient threatens to harm someone
    When your patient must be restrained
    When your patient is anxious
    When your patient threatens suicide
    When your patient accidentally injures herself
    When your patient is caught smoking
    When your patient has contraband
    When your patient tampers with medical equipment
    When your patient hides his drugs
    When your patient removes her endotracheal tube
    When your patient removes his chest tube
    When your patient speaks a different language
    When your patient has a hearing impairment
    When your patient has a vision impairment
    When your patient is obese- NEW!
    When your patient can't give informed consent
    When your patient doesn't understand the procedure he's about to undergo
    When your patient's equipment fails
    When your patient's belongings are missing
    When your patient's family questions the quality of care
    When you suspect that your patient has been abused
    When your patient's visitors won't leave
    When your patient is seriously ill- NEW!
    When your patient asks you to witness her last will and testament
    When a patient dies
    When your patient donates an organ

    Part 3: Handling Difficult Professional Problems
    When a physician or colleague illegally alters the medical record
    When a colleague criticizes your care in the medical record
    When you find an inappropriate comment in the medical record
    When a physician asks to remove a medical record from the facility
    How to handle a physician's questionable order
    When you take a telephone or verbal order
    When a physician's order is illegible
    When a colleague asks you to document her care
    When a coworker gives your patient drugs in your absence
    When you suspect that a colleague is negligent
    How to document care given by unlicensed assistive personnel
    When you're asked to countersign a colleague's notes
    When you must work on an understaffed unit
    When your patient or her family asks you for medical advice
    When the physician and family decide to terminate the patient's life support
    When the physician writes a “do not resuscitate” order
    When you withhold a prescribed drug or other patient care
    When someone asks to photograph or videotape your patient
    When a member of the media asks for patient information
    When your patient is transferred or discharged
    How to make a late entry
    How to use abbreviations safely
    How to complete an incident report
    How to avoid the pitfalls of computer documentation
    How to protect your patient's privacy when faxing medical records
    How to protect patient confidentiality when using the Internet

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