Mosby's Surefire Documentation

2nd Edition

How, What, and When Nurses Need To Document

Author:

  • 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

About the author