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Title SkillMasters : better documentation / Jennifer P. Kowalak, senior associate editor ; copy editors Kimberly Bilotta [and four others] ; Risa Clow, Robert Dieters, cover design
Edition First edition
Published Philadelphia, Pennsylvania : Lippincott Williams & Wilkins, 2003
©2003

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Description 1 online resource (217 pages) : illustrations
Contents Cover; Copyright; Contributors and consultants; Foreword; Contents; 1 -- Fundamentals of documentation; 2 -- Legal aspects of documentation; 3 -- Documentation systems; 4 -- Documenting in acute care; 5 -- Documenting in long-term care; 6 -- Documenting in home care; 7 -- Documenting in special situations; Appendix A: Commonly accepted abbreviations; Appendix B: Commonly accepted symbols; Appendix C: NANDA Taxonomy II codes; Selected References; Index
Summary This portable reference is a timesaving guide on how to enhance charting skills, avoid legal pitfalls, and ensure that a complete and accurate record is created every time. Reviews fundamental aspects of charting, nursing process, legal and professional requirements, guidelines for developing a solid plan of care, and the variety of charting forms currently in use, including computerized charting. Completed forms show exactly how to document assessment, intervention, and evaluation. Also addresses the specific requirements for charting in acute care, home care, and long-term care and rehabilit
Bibliography Includes bibliographical references and index
Notes Online resource; title from PDF title page (ebrary, viewed May 7, 2014)
Subject Nursing records -- Handbooks, manuals, etc
Nursing records.
Nursing Records
Documentation -- methods
Forms and Records Control
Nursing records.
Genre/Form Handbooks and manuals.
Handbooks and manuals.
Form Electronic book
Author Kowalak, Jennifer P., editor
Bilotta, Kimberly, editor
Clow, Risa, cover designer
Robert, Dieters, cover designer
ISBN 9781469881041
1469881047