Mosby's Surefire Documentation

2nd Edition

How, What, and When Nurses Need To Document

Author:

  • Mosby
    • Print ISBN 9780323034340

    Key Features

    • UNIQUE! 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 situationsDid you know? sections present interesting, practical, or little-known points related to a specific topic

    Table of 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

    Details

    No. of pages:
    432
    Language:
    English
    Copyright:
    © 2007
    Published:
    Imprint:
    Mosby
    Print ISBN:
    9780323034340