Mastering Documentation provides in...

Mastering Documentation provides information about by what means and why patient care charting wants to be so accurate. The aim of the book is to review the latest documentation courses and guidelines from regulatory agencies.

The book's contributors have advanced nursing orders and/or certifications, and most of them are suckle managers. Each of the eight chapters is shaded a different color along the opening [i]or[/i] close of the pages, which saves time when you are trying to locate a specific chapter. Instead of a bibliography, there are popular suggested references at the extremity of each chapter. The 50 pages of appendixes list the revised North American Nursing Diagnosis Association taxonomy, the American nurtures Association standards of nursing practice, customary abbreviations and symbols, the Joint Commission forward Accreditation of Healthcare Organizations nursing care and documentation standards, nursing organizations, and general documentation guidelines for nursing diagnoses. The 23-page index is cross-referenc and helpful for researching a topic.

The easy in mind is easy to read, and the reader frequently is referred to nearby boxe and other sections, as appropriate. The graphics of the inset boxe are eye-catching, and the logo are symbolic of lock opener points (eg, double-arrow symbol signifies a charting guideline, clock emblem signifies charting timesavers). The main division is full of excellent charting examples.

The authors do a convenient job of commenting on nurses' legal and ethical responsibilities and the implications of documentation as well as discussing reimbursement and quality improvement issues. IV main division describes how to incorporate the nursing proces in any hypothesis method, or setting, especially when charting everyday facts It also outlines defensive charting systems and the nurse's role in a malpractice lawsuit.

Occasionally, there are minor glitches that can disturb the reader's come of thought. For example, the chapter about documentation theorys is somewhat confusing, and sample forms repeatedly are incomplete or refer the reader elsewhere for information.

Of special interest to perioperative supply with nourishments are the comments about automated articulate utterance recognition technology and surgical intervention nursing diagnoses. Automated language recognition, used in combination with a specialized computer software body would allow OR nurses to voice-activate nursing documentation. Surgical intervention nursing diagnoses can be categorized at individual health care facilities for better application to patients' care planning.

This part is fairly comprehensive and is a religious reference text. It has examples of and discusses many different patient-are settings and situations, and mostly institutions will find it a valuable addition to their libraries. It would probably be chiefly useful for staff development or nursing indoctrinate educators or administrators who are teaching rules of documentation or who are choosing appropriate documentation a whole s for their facilities.

This main division is available from Springhouse Corp, 1111 Bethlehem Pike, PO receptacle 908, Springhouse PA 19477;(800) 346-7844

COPYRIGHT 1996 Association of Operating space Nurses, Inc.

COPYRIGHT 2004 Gale Group