Documentation and the Nursing Process

Name: Documentation and the Nursing Process
Price: 100.75 USD
Availability: InStock
ISBN: 9780766850095

ISBN-10: 0766850099

ISBN-13: 9780766850095

Edition: 2003

Authors: Lois White

List price: $99.95

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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.

Book details

List price: $99.95
Copyright year: 2003
Publisher: Delmar Cengage Learning
Publication date: 8/15/2002
Binding: Paperback
Pages: 160
Size: 5.50" wide x 8.25" long x 0.75" tall
Weight: 0.682

Nancy Tye-Murray is a professor in the Department of Otolaryngology at Washington University School of Medicine in St. Louis, and an Adjunct Professor at New Zealand's University of Canterbury. A founder of the University of Iowa Cochlear Implant Aural Rehabilitation Programs, she also served as Director of Research for Central Institute for the Deaf. In addition to developing several communication strategies training programs, auditory training programs, and speechreading tests, Dr. Tye-Murray is the principle investigator of three National Institutes of Health RO1 grants. Her research focuses on the effects of aging on audiovisual speech recognition, discourse comprehension, and auditory…



Preface


Organization


Features


Acknowledgments


About the Author


Reviewers



Nursing Process



Nursing Process


Introduction


Historical Perspective


Overview of the Nursing Process


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


Introduction


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


Introduction


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


Introduction


Planning


Prioritizing the Nursing Diagnoses


Identifying Outcomes


Goals


Expected Outcomes


Developing Specific Nursing Interventions


Categories of Nursing Interventions


Recording the Nursing Care Plan



Implementation


Introduction


Requirements for Effective Implementation


Types of Nursing Interventions


Documenting and Reporting Interventions



Evaluation


Introduction


Evaluation


Nursing Audit


Case Study



Documentation



Documentation As Communication


Introduction


Documentation Defined


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



Principles of Effective Documentation


Introduction


Follow the Nursing Process


Elements of Effective Documentation


Accurate, Complete, and Objective


Date and Time


Use Appropriate Forms


Identify the Client


Write in Ink


Use Standard Abbreviations


Spell Correctly


Write Legibly


Correct Errors Properly


Write on Every Line


Chart Omissions


Sign Each Entry


Documenting a Medication Error


Medication Incident Report



Methods of Documentation


Introduction


Narrative Charting


Source-Oriented Charting


Problem-Oriented Charting


PIE Charting


Focus Charting


Charting by Exception


Computerized Charting


Point-of-Care Charting


Critical Pathway



Forms for Recording Data


Introduction


Kardex


Flow Sheets


Nurses' Progress Notes


Discharge Summary



Trends in Documentation


Introduction


Nursing Minimum Data Set


Nursing Diagnoses


Nursing Interventions Classification


Nursing Outcomes Classification



Reporting


Introduction


Summary Reports


Walking Rounds


Telephone Reports and Orders


Incident Reports


Appendices



NANDA Nursing Diagnoses 2001-2002



Abbreviations, Acronyms, and Symbols



Answers to Review Questions


Glossary


Index