Nursing Documentation Handbook

This pocket-size guide saves nurses precious time while ensuring that a complete patient record is created and that legal, quality assurance, and reimbursement requirements are met. This handbook provides specific verbiage for charting patient progress, change or tasks accomplished for approximately 50 common problems. The new third edition has been completely updated to include Critical Assessment Findings, Subjective Findings for Documentation, Resources for Care and Practice, Legal Considerations, Time Saving Tips, and new Managed Care information. Plus, roughly 15 additional common problems and diagnoses have been added making this practical resource more valuable than ever. Diagnoses are in alphabetical order allowing for fast and easy access.

Each patient problem or diagnosis found in this handbook includes specific documentation guidelines for the following aspects of nursing care:

*Assessment of patient problem

*Associated nursing diagnosis

*Examples of objective findings for documentation

*Examples of subjective findings for documentation

*Examples of assessment of the data

*Examples of potential medical problems for this patient

*Examples of the documentation of potential nursing interventions/actions

*Examples of the evaluations of the interventions/actions

*Other services that may be indicated and their associated interventions and

goals/outcomes

*Nursing goals and outcomes

*Potential discharge plans for this patient

*Patient, family, caregiver educational needs

*Resources for care and practice

*Legal considerations for documentation, as appropriate

Introductory chapters describe documentation, the medical record systems of nursing documentation, and current JCAHO and ANA standards related to documentation.

Specialty sections provide important and specific guidelines for hospice care and maternal-child care.

Appendices provide the latest NANDA-approved nursing diagnoses, descriptions of services provided by other disciplines, abbreviations, and a listing of resources (i.e., directory of resources, clinical newsletters and journals, Internet resources, further reading).

Includes Time Saving Tips boxes to help minimize the time needed for documentation responsibilities.

Each diagnosis includes a Critical Assessment Components/Findings section to help nurses with their critical decision making and determine whether an assessment finding indicates immediate attention or patient follow up.

The Goals/Outcomes section of each diagnosis now appears at the beginning so that nurses know the intended goals and outcomes up front before beginning the assessment.

All documentation guidelines now include sections on Examples of Subjective Findings for Documentation and Resources for Care and Practice.

Includes Legal Considerations for Documentation as appropriate to highlight important legal issues.

Part One has been updated to reflect the current managed care environment, including new information required by the National Community of Quality Assurance [NCQA], so that nurses can incorporate and focus on these changes as they document.