Mosby's Surefire Documentation: How, What, And When Nurses Need To Document, 2e Download Free (EPUB, PDF)
Mosby's Surefire Documentation, 2nd Edition offers clear, practical guidelines for how, what, and when to document for more than 100 of the most common and most important situations nurses face. Divided into 3 sections ― Caring for Patients, Dealing with Challenging Patient Situations, and Handling Difficult Professional Problems ― this essential resource details exactly what information to consider and document, to ensure quality patient care, continuity of care, and legal protection for the nurse and the institution where the nurse works.UNIQUE! Case histories that illustrate key legal pointsTips to help nurses streamline documentation without sacrificing accuracyGuidance for documenting unusual or difficult developments or eventsClear, concise explanations of complex legal terms and conceptsAdvice on how and why to document for a variety of documentation systemsCharting Checklists identify essential points to record for a particular situationLegal Briefs explain legal terms, such as a living will, or give practical advice for avoiding legal pitfallsCase Law Close-Ups describe specific court cases, explain the court's ruling, and point out the nursing implicationsTips and Advice help the nurse solve documentation problems, such as correcting a mistaken entry, and give advice on recording data in complex situationsDid you know? sections present interesting, practical, or little-known points related to a specific topicCompletely 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
Paperback: 384 pages
Publisher: Mosby; 2 edition (February 1, 2006)
Language: English
ISBN-10: 0323034349
ISBN-13: 978-0323034340
Product Dimensions: 6.4 x 0.7 x 9 inches
Shipping Weight: 1.2 pounds (View shipping rates and policies)
Average Customer Review: 4.1 out of 5 stars See all reviews (16 customer reviews)
Best Sellers Rank: #188,952 in Books (See Top 100 in Books) #111 in Books > Textbooks > Medicine & Health Sciences > Administration & Policy > Medical History & Records #131 in Books > Medical Books > Administration & Medicine Economics > Medical History & Records #155 in Books > Textbooks > Medicine & Health Sciences > Nursing > Reference
I am a director on a nursing unit and I cannot stress enough with the new graduates how very important their documentation is! I buy this book as a gift to all for all of the new graduates when they complete their 16 week internship! I wish someone had given me this book . . . .but then I graudated 34+ years ago . . .and this book had not been published! Easy to read, down-to-earth and just an all around fantastic reference book for any nurse - new or experienced! Kudos to the authors!
I'm a first year nursing student. Learning how to document leaves us pretty much on our own to figure out. This recommended book has truely helped me acquire a better sense of the whole documentation process. I took a 4 hour workshop at school and this documentation process wasn't covered. I would strongly recommend this book. I give this 5 stars.
I am a recent grad and I just finished my orientation on a tele floor. I feel like the one thing schools and jobs don't teach you is proper documentation. And every nurse documents differently. I wanted to sign up for the NYSNA course that is offered every so often on proper documentation but it won't be offered for awhile. This book is short sweet and presents a whole variety of situations that we can face. Documentation is key to patient care and protecting our license.
didn't care for this book it was a good description of what today but I was looking for a book with examples of what actually documentation was needed like chart smart a to z
The product is a must in healthcare settings especially for the new nurses in the field. It tells you step by step what to document in the nursing setting!
This book did not go far enough and did not meet the needs of the current electronic charting environment. Was looking for recommendations and guidelines for frequency of documenting in today's environment - this book fell short of my needs. We use the Mosby's online resource for our clinical staff and to support our P&Ps - this was not the "surefire" resource I was looking for.
Being a practicing nurse out from school dose not give you enough skills in narrating the actions you have done for your patients. This book is a very good guide to lessen your worries of how to document and removes your dependency to nurses who might be too busy to guide you...Good luck
Sometimes you just want a quick answer. If u are really, really busy and you want to thumb through this book for a generalized idea of a quick documentation quote, this is not the book for you.
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