Nursing documentation reduce your risk of liability by Patricia A. Duclos-Miller

Cover of: Nursing documentation | Patricia A. Duclos-Miller

Published by HCPro in Marblehead, MA .

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Edition Notes

Book details

StatementPatricia A. Duclos-Miller
LC ClassificationsRT50 .D83 2007
The Physical Object
Paginationiv, 26 p. ;
Number of Pages26
ID Numbers
Open LibraryOL24453353M
ISBN 109781601460356
LC Control Number2010287174

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nursing documentation that is used throughout an organization. ANA’s Principles for Nursing Documentationidentifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings.

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Our nursing program has offered no formal training in documentation (!) so i am looking on a charting book with info on all the different charting formats (i.e problem based charting, charting by exception) as well as how to write admission/discharge notes in different clinical settings (i.e med/surg, obs, emerg) and of course how to soap note.

Involves recording the interventions carried out to meet the patient's needs. Done in a proper way, it reflect the nursing process. Necessary to prove that nursing work was done.

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The Oncology Nursing Society (ONS) is proud to introduce new documentation standards for cancer treatment. The standards were developed by a task force of experts in various specialty treatment areas and ONS nursing staff using recommended elements of documentation established by the American Nurses Association to ensure accuracy, thoroughness, and.

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Check Out Our Nursing Documentation Essay Documenting objective and subjective data helps to identify and address problems in healthcare, and constitutes an important step in health assessment. Accurate recording of patient data fosters the success of nursing by providing health care teams with data that is vital concerning the evaluation of.

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Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with Price: $   Proper and accurate documentation is essential to avoid types of nursing documentation errors, and for helping to avoid patient deaths or increased liability for the caregiving facility, physician, or nurse.

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The nurse also documents the time and content of two calls made to the patients physician requesting that the physician examine the patient for. Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse.

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Identify documentation practices that validate safe, effective, and high quality patient-centered care. Identify documentation practices that create legal and professional risks.

Identify characteristics of nursing documentation that support a legal defense of nursing actions. We are gradually moving to this method of documentation.

Currently, we have 18 care plan templates covering over 40% of the patients admitted to our hospital and the number continues to grow. 20 Documentation Dos and Don’ts. Nursing documentation includes any and all forms of documentation by a nurse or midwife recorded in a professional capacity and in relation to the provision of nursing care.

This video collection explains concisely what nursing documentation is and presents 20 fundamental principles of sound nursing documentation. Nursing Documentation Remember the old saying, “if it wasn’t documented, it wasn’t done.” The purpose of the medical record is to provide a clear and accurate picture of the patient while under the care of the healthcare team (Campos, ).

A good general nursing book will explore oncology, pharmacology, and the medical terminology, yet will place just as much importance on nutrition, hematology, and the study of the endocrine system.

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Background: Nursing has an obligation to the public to develop measures for the quality of care to enhance patient safety and efficiency of the system.

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The quality of nursing documentation is an important issue for nurses both nationally and internationally. Nursing documentation should, but often. Presents a guide to nursing documentation. This handbook enables nurses to chart quickly by providing specific verbiage for charting patient progress, change, or tasks accomplished for approximately Read more.

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NURSING DOCUMENTATION IN CLINICAL PRACTICE ORIGINAL PAPERS This thesis is based on the following papers, which will be referred to by their Roman numerals: I Development of an audit instrument for nursing care plans in the patient record.

Björvell C, Thorell-Ekstrand I, Wredling R. Quality in Health Care ,9,File Size: KB. Description. This full-color handbook is a quick-reference guide to all aspects of documentation for every nursing care situation.

This handbook covers current documentation systems and formats, including computerized documentation, and features scores of sample filled-in forms and in-text narrative notes illustrating everything from everyday occurrences to emergency situations.- Explore bebblyanderson's board "Nursing: Documentation Tools", followed by people on Pinterest.

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