Mosby's Surefire Documentation: How, What, and When Nurses Need To Document

Mosby's Surefire Documentation, Second Edition, uses clear concise reading style to give specific, practical advice of how, what, and when to document over 100 of the most common and most important situations nurses face. Divided into 3 sections: Caring for Patients; Dealing with Special Situations; and Practicing Yourself Legally; each entry tells exactly what to consider and document, so that nurses can ensure quality patient care, continuity of care, and legal protection. The second edition will be thoroughly updated to reflect the latest HIPAA and JCAHO recommendations and standards as well as the most current legal tips and advice. A special emphasis will be placed on the evolving role and means of electronic documentation in the clinical setting. 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 situations Did 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