Complete Guide to Documentation

This comprehensive documentation reference is the most up-to-date book of its kind written for nurses. Complete Guide to Documentation is organized into four sections. Section 1 presents an overview of documentation basics, including the medical record, elements of good documentation, policies affecting documentation, legal and ethical considerations, quality management and reimbursement, documentation systems, and computerized documentation. Section 2 discusses documentation for acute care, outpatient or ambulatory care, home care, and long-term, extended care, and rehabilitation. Section 3 provides sample documentation for several clinical situations. Section 4 discusses how to document care given in selected clinical specialties and current documentation trends. Special features of the guide include filled-in documentation forms and samples, regulatory guidelines relating to documentation, and a glossary. Appendices cover approved nursing abbreviations, standards of nursing practice, and guidelines for documenting common nursing diagnoses. Graphic icons are used throughout the book to draw attention to tips on smarter charting, technology’s use in documentation, checklists, court cases, legal information, and sample documentation forms.