Nursing Documentation: A Nursing Process Approach

NURSING DOCUMENTATION: A NURSING PROCESS APPROACH clearly and concisely provides guidelines for appropriate and careful documentation of care. Accurate documentation shows managed care companies that patients receive adequate care and that health care providers are controlling costs and resources. In addition, it plays a large role in how third party payors make payment or denial decisions. This new edition includes the latest changes and trends in nursing documentation as related to the newly restructured healthcare environment. Special attention focuses on the latest documentation issues specific to specialty settings, such as acute care, home care, and long-term care, and a variety of clinical specialties, such as obstetrics, pediatrics, and critical care.

* Applies principles of documentation using practical examples, scenarios, and case studies. * Organizes documentation concerns based on the five-step nursing process. * Incorporates the most current JCAHO standards and NANDA taxonomy as they relate to documenting care. * Includes Home Care Documentation section, which provides information about unique considerations in documentation of home care, such as proper documentation for reimbursement, computerized patient records, and continuity of services. * Contains Long-Term Care Documentation chapter, which focuses on specific documentation information for long-term care, including proper documentation for Medicare, Resident Assessment Protocols, and interdisciplinary care planning. * Written in a clear and concise manner.

Patricia W. Iyer, RN, MSN, CNA is President, Patricia Iyer Associates, Med League Support Services, Inc., Flemington, NJ.