Mosby's Surefire Documentation : How, What, and When Nurses Need to Document
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Mosby's Surefire Documentation, Second Edition, uses clear concise reading style to give specific, practical advice of how, what, and when to document over 100 of the most common and most important situations nurses face. Divided into 3 sections: Caring for Patients; Dealing with Special Situations; and Practicing Yourself Legally; each entry tells exactly what to consider and document, so that nurses can ensure quality patient care, continuity of care, and legal protection. The second edition will be thoroughly updated to reflect the latest HIPAA and JCAHO recommendations and standards as well as the most current legal tips and advice. A special emphasis will be placed on the evolving role and means of electronic documentation in the clinical setting.