Mosby's Surefire Documentation, 2nd Edition offers clear, practical guidelines for how, what, and when to document for more than 100 of the most common and most important situations nurses face. Divided into 3 sections Caring for Patients, Dealing with Challenging Patient Situations, and Handling Difficult Professional Problems this essential resource details exactly what information to consider and document, to ensure quality patient care, continuity of care, and legal protection for the nurse and the institution where the nurse works.
- UNIQUE! Case histories that illustrate key legal points
- Tips to help nurses streamline documentation without sacrificing accuracy
- Guidance for documenting unusual or difficult developments or events
- Clear, concise explanations of complex legal terms and concepts
- Advice on how and why to document for a variety of documentation systems
- Charting Checklists identify essential points to record for a particular situation
- Legal Briefs explain legal terms, such as a living will, or give practical advice for avoiding legal pitfalls
- Case Law Close-Ups describe specific court cases, explain the court's ruling, and point out the nursing implications
- Tips and Advice help the nurse solve documentation problems, such as correcting a mistaken entry, and give advice on recording data in complex situationsDid you know? sections present interesting, practical, or little-known points related to a specific topic
- Completely updated content throughout that reflects the latest information and guidelines affecting documentation, including HIPAA and JCAHO standards.
- Expanded coverage of electronic documentation and its implications for nurses.
- A wealth of new and expanded special features such as Charting Checklists, Legal Briefs, and Case Law Close-Ups that further illustrate important documentation and legal considerations
