Nursing Notes the Easy Way: 100+ Common Nursing Documentation and Communication Templates
Nursing Notes the Easy Way: 100+ Common Nursing Documentation and Communication Templates
2nd Edition of the popular book published by Nursethings! SUPER PRACTICAL because it is to the point and easy to use! Ever wonder what to put in a nursing note? Not sure what to say when giving report or calling the physician? This pocket sized guide provides you with over a hundred templates for written and verbal communication so you will never be at a loss for words. Knowing what should be documented for a given nursing situation also helps you be sure you are thorough in your care. Templates are helpful for ESL nurses who may struggle with terminology or syntax in communication.
- ASIN: 0975999869
- ISBN: 0975999869
- Manufacturer: Nursethings
Mosby's Surefire Documentation: How, What, and When Nurses Need To Document
Mosby's Surefire Documentation: How, What, and When Nurses Need To Document
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 situations
- ASIN: 0323034349
- ISBN: 0323034349
- Manufacturer: Mosby
Chart Smart: The A-to-Z Guide to Better Nursing Documentation
Chart Smart: The A-to-Z Guide to Better Nursing Documentation
This portable handbook shows nurses in all practice settings exactly what to document in any situation. Nearly 300 alphabetically organized entries cover diseases, emergencies, procedures, legal and ethical problems, and difficult situations involving patients, families, and other health care professionals. Legal Casebooks provide examples of legal implications of documentation. AccuChart sample forms show how to accurately complete various forms. Thoroughly updated to reflect current practice, this Second Edition provides information on the electronic health record. New entries cover situations such as surgical site verification, patient glucose self-testing, cultural needs identification, HIPAA, and reporting critical test values. A new appendix covers prohibited abbreviations.
- ASIN: 1582559872
- ISBN: 1582559872
- Brand: Brand: Lippincott Williams Wilkins
- Manufacturer: LWW
Handbook of Home Health Standards - Revised Reprint: Quality, Documentation, and Reimbursement (Handbook of Home Health Standards & Documentation Guidelines for Reimbursement)
Handbook of Home Health Standards - Revised Reprint: Quality, Documentation, and Reimbursement (Handbook of Home Health Standards & Documentation Guidelines for Reimbursement)
Handbook of Home Health Standards: Quality, Documentation, and Reimbursement includes everything the home care nurse needs to provide quality care and effectively document care based on accepted professional standards. This handbook offers detailed standards and documentation guidelines including ICD-9-CM (diagnostic) codes, OASIS considerations, service skills (including the skills of the multidisciplinary health care team), factors justifying homebound status, interdisciplinary goals and outcomes, reimbursement, and resources for practice and education. The fifth edition of this "little red book" has been updated to include new information from the most recently revised Federal Register Final Rule and up-to-date coding. All information in this handbook has been thoroughly reviewed, revised, and updated.
- ASIN: 0323084400
- ISBN: 0323084400
- Brand: Brand: Mosby Inc 2011-06-30
- Manufacturer: Mosby
Nursing Care Plans and Documentation: Nursing Diagnoses and Collaborative Problems
Nursing Care Plans and Documentation: Nursing Diagnoses and Collaborative Problems
The Fifth Edition of Nursing Care Plans and Documentation provides nurses with a comprehensive guide to creating care plans and effectively documenting care. This user-friendly resource presents the most likely diagnoses and collaborative problems with step-by-step guidance on nursing action, and rationales for interventions. The author also details research for individuals and families undergoing diagnostic procedures or medical and surgical interventions. The book includes over 70 care plans that translate theory into clinical practice.A new chapter covers moral distress in nursing and presents strategies to reduce its effect on nurses. An innovative new chapter on wellness discusses how to improve hospitalized patient outcomes. Other new topics covered include nursing diagnosis risk for compromised human dignity.
- ASIN: 0781770645
- ISBN: 0781770645
- Brand: Brand: LWW
- Manufacturer: LWW
Nursing Care Plans: Transitional Patient & Family Centered Care (Nursing Care Plans and Documentation)
Nursing Care Plans: Transitional Patient & Family Centered Care (Nursing Care Plans and Documentation)
Learn how to create nursing care plans, effectively document care, and succeed in the course withNursing Care Plans: Transitional Patient and Family Centered Care, Sixth Edition. Easy-to-understand and packed with practical tools to prepare you for clinical practice, this proven bookfocuses on the nursing plans that are most important, ensuring that you learn what you need to know and that you can find the information you need easily, without being distracted by irrelevant information. · Maximize your study time with Chapter 1’s step-by-step guidance on how to use the text, including a guide on how to use the book’s icons.· Learn the various considerations to keep in mind when creating nursing care plans throughSafety and Qualityicons that use a scale of 1-5 to show risk severity and include suggestions for action.· Increase your recall of important information with new, true-to-practice briefer interventions developed by expert clinicians.· See how theory translates into practice with more than 85 sample nursing care plans.· Broaden your knowledge with new care plans for Maternity, Pediatrics, and Mental Health.· See the importance of evidence-based practice through new evidence-based rationales and guidelines.· Experience anytime, anywhere access to day-to-day encounters and special risk information with theLaminated Quick Reference Information Card.· Easily design your own care plans with theCare plan CreatoronthePoint.· Master each chapter’s content withChapter Openersthat include background, diagnostic cluster, discharge criteria, and collaborative problems.· Find the information you need fast with a user-friendly format that splits Collaborative Problems and Nursing Diagnosis in each chapter and organizes care plans by Medical Conditions, Surgical Procedures, and Diagnostic and Therapeutic Procedures.· Prepare for effective nursing practice with NIC & NOC cited prior to interventions and helpful author notes that provide advice on how to imple... [Read More]
- ASIN: 1451187874
- ISBN: 1451187874
- Manufacturer: LWW
The Omaha System: A Key to Practice, Documentation, and Information Management
The Omaha System: A Key to Practice, Documentation, and Information Management
The definitive resource on the Omaha System...This book explains the integration of the Omaha System's Problem Classification Scheme (assessment), the Intervention Scheme (plans, pathways, and services), and the Problem Rating Scale for Outcomes (evaluation). It is designed to help improve the accuracy, consistency, ease, and speed of clinical documentation across diverse health care settings. It encourages critical thinking and offers a best practices/evidence-based practice approach to health care.For practice: You can use the Omaha System to focus care, increase partnership with clients/patients and standardize documentation. You can also generate powerful reports and increase the visibility of health care services by converting your outcome data into compelling illustrated trends and graphics.For education: As an educator, you can use the Omaha System to introduce characteristics of professional practice and quality care, decision-making skills, and a standardized terminology. As a student, the relatively simple, intuitive, and hierarchical Omaha System can help you understand a problem-solving approach to practice and the benefits of effective documentation.For research: As an investigator, you can build on the rich foundation of Omaha System research, a foundation that is becoming increasingly diverse. You can advance the science of practice and generate findings of practical, economic, and professional value.For informatics: The Omaha System exists in the public domain, is recognized by the American Nurses Association, is mapped to SNOMED CT, and is integrated into LOINC. Thus, it can be the basis of automated clinical information systems that meet interoperability standards and requirements.Key features:Terms, definitions, and codes can be easily understood by various health care professionals nationally and globallyBook and chapters are authored by award-winning Omaha System experts including Karen Martin, Karen Monsen, Vicky Elfrink, and Kathy Bowles18 c... [Read More]
- ASIN: 0721601308
- ISBN: 0721601308
- Brand: Brand: Health Connections Press
- Manufacturer: Health Connections Press
Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (Handbook of Home Health Standards & Documentation Guidelines for Reimbursement)
Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (Handbook of Home Health Standards & Documentation Guidelines for Reimbursement)
Handbook of Home Health Standards: Quality, Documentation, and Reimbursement includes everything the home care nurse needs to provide quality care and effectively document care based on accepted professional standards. This handbook offers detailed standards and documentation guidelines including ICD-9-CM (diagnostic) codes, OASIS considerations, service skills (including the skills of the multidisciplinary health care team), factors justifying homebound status, interdisciplinary goals and outcomes, reimbursement, and resources for practice and education. The fifth edition of this “little red book has been updated to include new information from the most recently revised Federal Register Final Rule and up-to-date coding. All information in this handbook has been thoroughly reviewed, revised, and updated.Offers easy-to-access and easy-to-read format that guides users step by step through important home care standards and documentation guidelinesProvides practical tips for effective documentation of diagnoses/clinical conditions commonly treated in the home, designed to positively influence reimbursement from third party payors.Lists ICD-9-CM diagnostic codes, needed for completing CMS billing forms, in each body system section, along with a complete alphabetical list of all codes included in the book in an appendix.Incorporates hospice care and documentation standards so providers can create effective hospice documentation.Emphasizes the provision of quality care by providing guidelines based on the most current approved standards of care.Includes the most current NANDA-approved nursing diagnoses so that providers have the most accurate and up-to-date information at their fingertips.Identifies skilled services, including services appropriate for the multidisciplinary team to perform.Offers discharge planning solutions to address specific concerns so providers can easily identify the plan of discharge that most effectively meets the patient’s needs.Lists the cru... [Read More]
- ASIN: 032305224X
- ISBN: 032305224X
- Manufacturer: Mosby
Nursing Know-How: Charting Patient Care (NurseNotes)
Nursing Know-How: Charting Patient Care (NurseNotes)
Nursing Know-How: Charting Patient Careoffers how-to guidance on the latest techniques and trends in documentation, equipping nurses with the "know-how" to efficiently and accurately document patient care admission to discharge. The book is written in paragraph and bulleted format, with hundreds of sample filled-in forms and narrative notes that demonstrate the best and safest charting techniques. Know-Howicons offer expert advice on how to document.Case Clipicons present clinical scenarios involving specific situations, and identify the role that a rapid response team plays in responding to the situation.Legal Lookouticons present legal advice about documentation and real-world court cases where careful nursing documentation is particularly vital.
- UPC: 000781791944
- ASIN: 0781791944
- ISBN: 0781791944
- Manufacturer: LWW
Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
The 10th edition of the Nursing Diagnosis Handbook makes formulating nursing diagnoses and creating individualized care plans a breeze. Updated with the most recent NANDA-I approved nursing diagnoses, this convenient reference shows you how to build customized care plans in three easy steps: assess, diagnose, plan. Authors Elizabeth Ackley and Gail Ladwig use Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) to guide you in creating care plans that include desired outcomes, interventions, patient teaching, and evidence-based rationales. Unique! Care Plan Constructor on the companion Evolve website offers hands-on practice creating customized plans of care. Alphabetical thumb tabs allow quick access to specific symptoms and nursing diagnoses.Suggested NIC interventions and NOC outcomes in each care plan. Recent and classic research examples promote evidence-based interventions and rationales. NEW! 4 Color textNEW! Includes updated 2012-2014 NANDA-I approved nursing diagnosesNEW! Provides the latest NIC/NOC, interventions, and rationales for every care plan.NEW! QSEN Safety interventions and rationalesNEW! 100 NCLEX exam-style review questions are available on the companion Evolve website.NEW! Root Causing Thinking and Motivational Interviewing appendixes on the companion Evolve website.
- ASIN: 0323085490
- ISBN: 0323085490
- Brand: Unknown
- Manufacturer: Mosby