Complete Guide to Documentation

by Lippincott Williams & Wilkins

Book Overview

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...

• Format: Hardcover
• Language: English
• ISBN: 158255238X
• ISBN13: 9781582552385
• Release Date: January 2003
• Publisher: Spring House / Emd
• Length: 448 Pages
• Weight: 1.85 lbs.
• Dimensions: 1.2" x 7.1" x 9.8"

Customer Reviews

Use this! It gets back to the basics!

I'm always drawn to books that either teach the basic principles, or build on the basic principles. This one does both. Some of the chapters are ho-hum for the experienced nurse. As a maternal-child nurse with 25+ years of experience, I probably could have written that section. Yet, content on frequency of documentation for the laboring patient, while not "new", prompts the reader to remember that frequency of documentation is related to the complexity of the labor and the medications given. A glaring omission in that section was documentation for the postpartum mother after the first hour. Most notably, the standard 8-point check--which seems to be nowhere in the nurse's skill set these days--should have been included. Overall, every chapter contained some tidbit of information that I was unaware of. Other chapters are great for the nurse who needs an update, or even just guidance for charting in a new facility or a different specialty. When I was in school SOAP notes were the big thing. This book gave several formats for charting e.g., PIE, AIR, POMR, and several others. These formats were also included on a table that described the features of each. There was also mention of several issues that simply weren't issues when I went to school, e.g., documenting abuse, faxing orders, and so forth. For the nurse who doesn't know much about computerized documentation, this is a great resource. Again, it sticks with the basic principles of how-to, but tackles questions like advantages of and disadvantages of computerized charting. (Let's face it, folks, we're all going to need to know how to do computerized patient records, sooner or later!) A weakness might be that I was unable to find a strong section on scope of practice as it relates to what the nurse cannot document. By this, I mean where the nurse crosses the line between nursing and medical practice. Also, the section on informed consent did not take on the nitty-gritty issues that nurses really face. In a future edition, I'd like to see the maternal-child section either re-named or plumped up. The new growth charts should also be included. Over the years, in multiple roles as staff nurse, clinical nurse specialist, administrator, or faculty member, I know that "somewhere" nurses are presumed to have accumulated the information that is in this book. Usually, its nowhere in their heads or their documentation. There is something for everyone in this book. Some will highlight every page, others will highlight only here and there, but it's a great resource for all. If you are a maternal-child nurse you may like my book. Breastfeeding the Newborn: Clinical Strategies for Nurses