Publication Year: 2007
Edition: 2nd Ed.
Publisher: Lippincott Williams & Wilkins (LWW)
Thoroughly updated for its second edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems.
This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting Joint Commission safety goals, and new information on charting pain management.
Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, Joint Commission documentation standards, and documenting outcomes and interventions for key nursing diagnoses.