This text focuses on important elements of documentation as they relate to steps in the nursing process including assessment, diagnosis, planning, interventions, outcomes and evaluation. This second edition contains real-life legal cases that include examples of improper documentation.
This is an essential book for anyone involved in reading medical records. It provides an overview of nursing charting, with a special focus on documentation issues specific to a variety of clinical areas. The third edition is bigger and better than ever with extensive revision and addition of legal cases to illustrate key points.
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