Table of Contents

Contributors and consultants Foreword Part I: Fundamentals 1 Nursing Documentation and the medical record 2 Legal and ethical implications of documentation 3 Quality management and reimbursement 4 Documentation systems 5 Documentation of the nursing process Part II: Documentation for every practice setting 6 Documentation in acute care 7 Documentation in long-term car 8 Documentation in home care 9 Documentation in outpatient and ambulatory care Part III: Documentation in action 10 Documentation of everyday events 11 Documentation of selected clinical specialties 12 Legally perilous documentation practices Part IV: Computerized documentation 13 Computerized patient records 14 The future of automated documentation Appendices A. JCAHO-approved nursing abbreviations B. JCAHO nursing care and documentation standards C. Commonly accepted abbreviations and symbols for documentation D. Documentation guidelines for common nursing diagnoses Inde