Table of Contents

More comprehensive and detailed than ever before, this fourth edition of Nursing Documentation: A Nursing Process Approach is an essential and valuable tool for your professional practice.  This book clearly and concisely presents the guidelines for appropriate and careful documentation of care. Nursing Documentation helps you analyze and interpret nursing charting and medical records.

This Newest Edition Includes:

• American Nurses Association 2004 Standards of Practice
  
• Tips for documenting pain assessment
  
• Liability associated with failure to treat pain effectively
  
• Nursing Outcomes Classification and Nursing interventions Classification
  
• Medications used to treat suffering
  
• Evidenced based interventions
  
• Critical thinking
  
• Updated legal cases
  
• The JCAHO “Do Not Use” abbreviations
  
• FACT charting
  
• Statistics on nursing home malpractice suits
  
• Analysis of 254 nursing home malpractice cases

Reviews for the third edition

Nursing Documentation: A Nursing Process Approach is an excellent resource book for nurses who are planning and implementing inservice activities and continuing education offerings on nursing documentation. Throughout the text and in the appendix, the authors have included several examples of documentation forms and tools, such as nursing assessment forms, patient teaching records, and flow sheets.
Mary Jane Ferrell, PhD, RN
Director, Staff Development
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania

Here is a well-written and illustrated overview of nursing documentation. Nursing Documentation will be useful for nursing students and staff nurses. The text is particularly relevant for committees charged with streamlining nursing documentation to improve cost effectiveness and for staff development educators charged with developing inservice programs on documentation systems. The style is readable and interesting. Sample forms are applicable to a wide range of clinical situations and are, therefore, useful as references.
Journal of Nursing Staff Development

Table of contents

Read the Preface (pdf)

Related books:

Medical Abbreviations

Nursing Home Litigation: Investigation and Case Preparation

Nursing Malpractice

Table of Contents

Detailed table of contents (pdf)

Overview of Documentation

Documenting Assessment

Documenting Nursing Diagnosis and Planning

Documenting Implementation

Documenting Evaluation

Legal Aspects of Charting Techniques

Charting Systems

Computerization of Nursing Information

Implementing Changes in Nursing Documentation Systems

Maternal-Child Documentation:

    Obstetrical Documentation, Neonatal Documentation, Pediatric Documentation

Critical Care Documentation:

    Emergency Documentation, Intensive Care Documentation

Perioperative Documentation:

    Operating Room Documentation, Postanesthesia Care Unit Documentation

Psychiatric Documentation

Home Care Documentation

Long Term Care Documentation

Contributing Authors
Barbara Ashley RN BSN MSN, Donna Cairone RN BS BSN CNOR RNFA, Rita Cavallaro RN,C LNHA MS, Gail Coplein BA JD, Joyce Hamlin MSN RN,C CS, Ann Marie Santarelli-Kretrovics RN BSN MS, Jo Anne Kuc RN BSN, Joanne McDermott RN BSN MA, Patrica Meadows RN BSN CEN, Pamela Meyer-Tulledge RN BSN MA, Joyce R. Newman RN,C CLNC C-GN, Rosie Oldham RN BS, Donna Ambler Peters RN PhD FAAN, Mary Kathryn Sadler RN BSN MBA CEN