The Nursing Documentation Handbook, ed 3 is an up-to-date and easy-to-use guide to complete, concise, and appropriate nursing documentation. This handbook enables nurses to chart quickly and thoroughly by providing specific verbiage for charting patient progress, change, or tasks accomplished for approximately 50 common problems or diagnoses. The thoroughness and practical organization of this book assists nurses in planning and individualizing patient care and ensures the creation of a complete patient record that satisfies legal, quality assurance, and reimbursement requirements. The use of this book ensures that appropriate nursing interventions are undertaken and documented in a timely fashion.
PART ONE:: The Principles of Documentation · Documentation:: An Overview · The Patient Record · Systems of Nursing Documentation · The Joint Commission on Accreditation of Healthcare Organizations Standards Related to Documentation · American Nurses Association Standards of Care · PART TWO:: Medical-Surgical Care Documentation Guidelines · Acquired Immune Deficiency Syndrome (AIDS) · Acute Myocardial Infarction · Alzheimers Disease and Other Dementias · Amputation · Angina · Asthma · Brain Tumor · Cancer Care · Cardiac Surgical Care · Cataract Care · Cerebrovascular Accident · Chemotherapy · Chronic Obstructive Pulmonary Disease · Congestive Heart Failure · Decubitus Ulcer · Diabetes Mellitus · Dialysis · Diarrhea · Enteral Care · Fracture Care · Gastrostomy Tube · Hypertension · Immobile Patient · Impaction · Intestinal Obstruction · Intravenous Therapy Care · Mastectomy Care · Osteoarthritis · Ostomy · Pain Management · Peripheral Vascular Disease · Pneumonia · Sickle Cell Anemia · Surgical Care · Tracheostomy Care · Tuberculosis · Urinary Catheter Care · Wound Care · PART THREE:: Specialty Care Documentation Guidelines · Hospice Care · Maternal-Child Care · APPENDIXES:: A) NANDA-Approved Nursing Diagnoses B) Services Provided by Other Disciplines C) Abbreviations D) Resources · BIBLIOGRAPHY
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