Documentation & the Nursing Process

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Documentation & the Nursing Process

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  • 製本 Paperback:紙装版/ペーパーバック版/ページ数 189 p.
  • 言語 ENG,ENG
  • 商品コード 9780766850095
  • DDC分類 651.504261

Full Description


This handbook offers a thorough overview of nursing documentation, and its importance, within the context of the nursing process. Users learn the principles of effective documentation and methods of documenting and examine trends relevant to this aspect of nursing care. Example forms are included to provide readers with hands-on experience with the documentation format.

Table of Contents

Preface                                            ix
Organization ix
Features x
Acknowledgments xi
About the Author xi
Reviewers xii
UNIT 1 NURSING PROCESS 1 (70)
Nursing Process 3 (12)
Introduction 3 (1)
Historical Perspective 4 (1)
Overview of the Nursing Process 5 (1)
The Nursing Process and Critical Thinking 6 (3)
The Nursing Process and Problem Solving 9 (1)
The Nursing Process and Decision Making 9 (1)
The Nursing Process and Holistic Care 10 (5)
Assessment 15 (16)
Introduction 15 (1)
Purpose of Assessment 16 (1)
Database 16 (1)
Collecting Data 16 (7)
Types of Assessment 16 (1)
Comprehensive Assessment 17 (1)
Focused Assessment 17 (1)
Ongoing Assessment 17 (2)
Sources of Data 19 (1)
Types of Data 20 (3)
Validating the Data 23 (1)
Organizing the Data 23 (3)
Hierarchy of Needs 24 (1)
Body Systems Model 24 (1)
Functional Health Patterns 25 (1)
Theory of Self-Care 25 (1)
Interpreting the Data 26 (1)
Documenting the Data 26 (5)
Diagnosis 31 (10)
Introduction 31 (3)
Components of a Nursing Diagnosis 34 (1)
Two-Part Statement 34 (1)
Three-Part Statement 34 (1)
Writing the Nursing Diagnosis Statement 35 (1)
Types of Nursing Diagnoses 35 (2)
Collaborative Problems 37 (4)
Planning and Outcome Identification 41 (14)
Introduction 41 (1)
Planning 42 (1)
Prioritizing the Nursing Diagnoses 42 (1)
Identifying Outcomes 43 (2)
Goals 43 (1)
Expected Outcomes 44 (1)
Developing Specific Nursing Interventions 45 (2)
Categories of Nursing Interventions 47 (1)
Recording the Nursing Care Plan 47 (8)
Implementation 55 (8)
Introduction 55 (1)
Requirements for Effective Implementation 56 (1)
Types of Nursing Interventions 57 (1)
Documenting and Reporting Interventions 58 (5)
Evaluation 63 (8)
Introduction 63 (1)
Evaluation 63 (3)
Nursing Audit 66 (2)
Case Study 68 (3)
UNIT 2 DOCUMENTATION 71 (108)
Documentation as Communication 73 (20)
Introduction 73 (1)
Documentation Defined 73 (1)
Purposes of Health Care Documentation 74 (19)
Communication 75 (1)
Education 75 (4)
Research 79 (1)
Legal and Practice Standards 80 (1)
Informed Consent 80 (2)
Advance Directives 82 (1)
State Nursing Practice Acts 83 (1)
Joint Commission on Accreditation of 84 (2)
Healthcare Organizations
Reimbursement 86 (7)
Principles of Effective Documentation 93 (16)
Introduction 93 (1)
Follow the Nursing Process 93 (2)
Elements of Effective Documentation 95 (7)
Accurate, Complete, and Objective 96 (1)
Date and Time 96 (2)
Use Appropriate Forms 98 (1)
Identify the Client 98 (1)
Write in Ink 98 (1)
Use Standard Abbreviations 99 (1)
Spell Correctly 99 (1)
Write Legibly 99 (1)
Correct Errors Properly 100(1)
Write on Every Line 100(1)
Chart Omissions 100(1)
Sign Each Entry 101(1)
Documenting a Medication Error 102(7)
Medication Incident Report 103(6)
Methods of Documentation 109(20)
Introduction 109(1)
Narrative Charting 110(1)
Source-Oriented Charting 111(1)
Problem-Oriented Charting 111(1)
PIE Charting 112(1)
Focus Charting 112(2)
Charting by Exception 114(1)
Computerized Charting 115(2)
Point-of-Care Charting 117(1)
Critical Pathway 118(11)
Forms for Recording Data 129(16)
Introduction 129(1)
Kardex 129(2)
Flow Sheets 131(3)
Nurses' Progress Notes 134(2)
Discharge Summary 136(9)
Trends in Documentation 145(10)
Introduction 145(1)
Nursing Minimum Data Set 146(1)
Nursing Diagnoses 146(1)
Nursing Interventions Classification 147(2)
Nursing Outcomes Classification 149(6)
Reporting 155(24)
Introduction 155(2)
Summary Reports 157(1)
Walking Rounds 157(2)
Telephone Reports and Orders 159(1)
Incident Reports 160(7)
APPENDICES
Appendix A NANDA Nursing Diagnoses 2001-2002 167(4)
Appendix B Abbreviations, Acronyms, and 171(4)
Symbols
Appendix C Answers to Review Questions 175(4)
Glossary 179(6)
Index 185