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Medical Book from C.H.I.P.S.

Documentation in Action
edited by Judith A. Schilling

Designed for rapid on-the-job reference, Documentation in Action offers comprehensive, authoritative, practice-oriented, up-to-the-minute guidelines for documenting every situation in every nursing practice setting and important nursing specialties.

Need-to-know information is presented in bulleted lists, charts, flow sheets, sidebars, and boxes, with icons and illustrative filled-in samples.

Coverage includes documentation for care of patients with various diseases, complications, emergencies, complex procedures, and difficulties involving patients, families, and other health care professionals.

Suggestions are given for avoiding legal pitfalls involving:

  • telephone orders
  • medication reactions
  • patients who refuse care, and much more!

Documentation in Action also addresses:

  • computerised documentation
  • HIPAA confidentiality rules
  • use of PDAs
  • nursing informatics
  • electronic innovations that will soon be universal

Contents

  1. Documenting everyday events
  2. Documenting from admission to discharge
  3. Legal and ethical implications of documentation
  4. Legally perilous documentation
  5. Computerized patient records
  6. Documentation in acute care
  7. Documentation in selected clinical specialty areas
  8. Documentation in ambulatory care
  9. Documentation in long-term care
  10. Documentation in home health care

Comparing documentation systems
Index

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Documentation in Action
edited by Judith A. Schilling
2006 408 pages $44.95 + shipping
Texas residents please add 6.75 % sales tax

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