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Documentation & the nursing process

Author: Lois White
Publisher: Clifton Park, N.Y. : Thomson/Delmar Learning, ©2003.
Edition/Format:   Print book : EnglishView all editions and formats
Summary:
"Documentation can be both overwhelming and absolutely critical. This concise text bridges the gap. This quick-reference handbook provides guiding principles as well as many practical examples of correct documentation. It is a must-have volume for the student and professional nurse in a clinical setting."--Jacket.
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Genre/Form: Handbooks and manuals
Handbooks
Handbooks, manuals, etc
Material Type: Internet resource
Document Type: Book, Internet Resource
All Authors / Contributors: Lois White
ISBN: 0766850099 9780766850095
OCLC Number: 49743666
Description: xii, 189 pages : illustrations ; 22 cm
Contents: Nursing Process --
Historical Perspective --
The Nursing Process and Critical Thinking --
The Nursing Process and Problem Solving --
The Nursing Process and Decision Making --
The Nursing Process and Holistic Care --
Assessment --
Purpose of Assessment --
Database --
Collecting Data --
Types of Assessment --
Comprehensive Assessment --
Focused Assessment --
Ongoing Assessment --
Sources of Data --
Types of Data --
Validating the Data --
Organizing the Data --
Hierarchy of Needs --
Body Systems Model --
Functional Health Patterns --
Theory of Self-Care --
Interpreting the Data --
Documenting the Data --
Diagnosis --
Components of a Nursing Diagnosis --
Two-Part Statement --
Three-Part Statement --
Writing the Nursing Diagnosis Statement --
Types of Nursing Diagnoses --
Collaborative Problems --
Planning and Outcome Identification --
Prioritizing the Nursing Diagnoses --
Goals --
Expected Outcomes --
Developing Specific Nursing Interventions --
Categories of Nursing Interventions --
Recording the Nursing Care Plan --
Implementation --
Requirements for Effective Implementation --
Types of Nursing Interventions --
Documenting and Reporting Interventions --
Evaluation --
Evaluation --
Nursing Audit --
Documentation --
Documentation As Communication --
Purposes of Health Care Documentation --
Communication --
Education --
Research --
Legal and Practice Standards --
Informed Consent --
Advance Directives --
State Nursing Practice Acts --
Joint Commission on Accreditation of Healthcare Organizations --
Reimbursement.
Other Titles: Documentation and the nursing process
Responsibility: Lois White.
More information:

Abstract:

"Documentation can be both overwhelming and absolutely critical. This concise text bridges the gap. This quick-reference handbook provides guiding principles as well as many practical examples of correct documentation. It is a must-have volume for the student and professional nurse in a clinical setting."--Jacket.

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