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Author: Patricia A. Duclos-Miller
Publisher:
Published: 2016
Total Pages:
ISBN-13: 9781683080695
DOWNLOAD EBOOKDownload or read book Improving Nursing Documentation and Reducing Risk written by Patricia A. Duclos-Miller and published by . This book was released on 2016 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt:
Author: Patricia A. Duclos-Miller
Publisher:
Published: 2016-06-30
Total Pages: 0
ISBN-13: 9781683080688
DOWNLOAD EBOOKImproving Nursing Documentation and Reducing Risk helps nurse managers create policies, processes, and ongoing auditing practices to ensure that complete and accurate documentation is implemented by their staff, without creating additional time burdens.
Download or read book Improving Nursing Documentation and Reducing Risk written by Patricia A. Duclos-Miller and published by . This book was released on 2016-06-30 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Improving Nursing Documentation and Reducing Risk helps nurse managers create policies, processes, and ongoing auditing practices to ensure that complete and accurate documentation is implemented by their staff, without creating additional time burdens.
Author: Patricia A. Duclos-Miller
Publisher: HC Pro, Inc.
Published: 2004
Total Pages: 166
ISBN-13: 9781578393954
DOWNLOAD EBOOKNurses are now commonly cited or implicated in medical malpractice cases.
Download or read book Managing Documentation Risk written by Patricia A. Duclos-Miller and published by HC Pro, Inc.. This book was released on 2004 with total page 166 pages. Available in PDF, EPUB and Kindle. Book excerpt: Nurses are now commonly cited or implicated in medical malpractice cases.
Author: Springhouse Corporation
Publisher:
Published: 1995
Total Pages: 424
ISBN-13:
DOWNLOAD EBOOKThe complete guide for streamlining and improving nursing documentation for virtually every system. Nurses will find instructions for virtually every common and not-so-common charting method. From progress notes to protocols, there is a wealth of easy-to-follow examples throughout the book. Includes JCAHO-approved nursing abbreviations, ANA standards of practive, and JCAHO and Medicare guidelines for nursing documentation.
Download or read book Mastering Documentation written by Springhouse Corporation and published by . This book was released on 1995 with total page 424 pages. Available in PDF, EPUB and Kindle. Book excerpt: The complete guide for streamlining and improving nursing documentation for virtually every system. Nurses will find instructions for virtually every common and not-so-common charting method. From progress notes to protocols, there is a wealth of easy-to-follow examples throughout the book. Includes JCAHO-approved nursing abbreviations, ANA standards of practive, and JCAHO and Medicare guidelines for nursing documentation.
Author: Kate Stout
Publisher: Lippincott Williams & Wilkins
Published: 2018-06-05
Total Pages: 312
ISBN-13: 1496394747
DOWNLOAD EBOOKPublisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more. Whether you are a nursing student or a new or experienced nurse, this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely, accurate, and watertight. Let the experts walk you through up-to-date best practices for nursing documentation, with: NEW and updated, fully illustrated content in quick-read, bulleted format NEWdiscussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices Easy-to-read, easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations, while addressing the different styles of charting Outlines the Do's and Don’ts of charting – a common sense approach that addresses a wide range of topics, including: Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation Documenting the patient’s health history and physical examination The Joint Commission standards for assessment Patient rights and safety Care plan guidelines Enhancing documentation Avoiding legal problems Documenting procedures Documentation practices in a variety of settings—acute care, home healthcare, and long-term care Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior Special features include: Just the facts – a quick summary of each chapter’s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans “Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.
Download or read book Nursing Documentation Made Incredibly Easy written by Kate Stout and published by Lippincott Williams & Wilkins. This book was released on 2018-06-05 with total page 312 pages. Available in PDF, EPUB and Kindle. Book excerpt: Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more. Whether you are a nursing student or a new or experienced nurse, this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely, accurate, and watertight. Let the experts walk you through up-to-date best practices for nursing documentation, with: NEW and updated, fully illustrated content in quick-read, bulleted format NEWdiscussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices Easy-to-read, easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations, while addressing the different styles of charting Outlines the Do's and Don’ts of charting – a common sense approach that addresses a wide range of topics, including: Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation Documenting the patient’s health history and physical examination The Joint Commission standards for assessment Patient rights and safety Care plan guidelines Enhancing documentation Avoiding legal problems Documenting procedures Documentation practices in a variety of settings—acute care, home healthcare, and long-term care Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior Special features include: Just the facts – a quick summary of each chapter’s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans “Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.
Author: Theresa Capriotti
Publisher: Lippincott Williams & Wilkins
Published: 2019-06-26
Total Pages: 499
ISBN-13: 1975120744
DOWNLOAD EBOOKFeeling unsure about documenting patient care? Learn to document with skill and ease, with the freshly updated Document Smart, 4th Edition. This unique, easy-to-use resource is a must-have for every student and new nurse, offering more than 300 alpha-organized topics that demonstrate the latest nursing, medical and government best practices for documenting a wide variety of patient conditions and scenarios. Whether you are assessing data, creating effective patient goals, choosing optimal interventions or evaluating treatment, this is your road map to documentation confidence and clarity.
Download or read book Document Smart written by Theresa Capriotti and published by Lippincott Williams & Wilkins. This book was released on 2019-06-26 with total page 499 pages. Available in PDF, EPUB and Kindle. Book excerpt: Feeling unsure about documenting patient care? Learn to document with skill and ease, with the freshly updated Document Smart, 4th Edition. This unique, easy-to-use resource is a must-have for every student and new nurse, offering more than 300 alpha-organized topics that demonstrate the latest nursing, medical and government best practices for documenting a wide variety of patient conditions and scenarios. Whether you are assessing data, creating effective patient goals, choosing optimal interventions or evaluating treatment, this is your road map to documentation confidence and clarity.
Author: Ronda Hughes
Publisher: Department of Health and Human Services
Published: 2008
Total Pages: 592
ISBN-13:
DOWNLOAD EBOOK"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
Download or read book Patient Safety and Quality written by Ronda Hughes and published by Department of Health and Human Services. This book was released on 2008 with total page 592 pages. Available in PDF, EPUB and Kindle. Book excerpt: "Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
Author: Carly Jane Wells
Publisher:
Published: 2017
Total Pages: 32
ISBN-13:
DOWNLOAD EBOOKBackground: Healthcare documentation not only allows for communication among healthcare providers and maintains patient care record keeping, it also archives essential information used to track, evaluate, and consider valuable healthcare interventions. When documented properly, this information can be used in research to assess international and national healthcare topics like standards of care, quality of care, complication and infection rates, and many more. When documentation is not complete ad comprehensive, a false representation can be made and a patient's safety is at risk. The American Nurse Association suggests nursing documentation be clear, accurate, complete, and accessible, allowing nurses to be responsible and held accountable for their documentation. Foreground: The inpatient unit of interest for this project, like many other hospital units, demands several hours of direct patient care, potentially leaving little time for complete documentation. As a consequence, documenting on important aspects of a patient's record, like the removal of any intravenous device (IVD), are missed or incomplete. When these pieces of information are missing, opportunities to provide accurate data regarding patients, fall short. Therefore, it was this project's objective to influence staff nurses to be as comprehensive as possible when documenting overall, and to see an improvement on the removal of any IVD documentation after providing an educational in-service. Theoretical and EBP Support: Lewin's Change Theory served as a supporting component in influencing and guiding the nurses of interest, transforming their care and making it a standard of practice when documenting on the removal of IVDs. In supporting this project's development, the Johns Hopkins Nursing Evidence-Based-Practice (EBP) Model served as guiding feature in the specific steps of EBP in nursing. Methods: Once both Institutional Review Boards granted approval for this Quality Improvement project, chart audits were performed within a three-week time frame pre- and post- nurse in-service. The provided in-service was given to staff nurses, float pool nurses, and nursing students over an 11-day period. The in-service included pertinent aspects of documentation, steps to improve current practice, which was supported by current evidence, and time for discussion regarding potential barriers to complete documentation. Findings: A clinically significant improvement of 11% was seen in comprehensive documentation on the removal of IVDs on a specific surgical patient population. The findings of this project predictively aligned with literature that supports the use of health information technology, like the electronic health record, were data are accurately and efficiently collected, which can be used to generate knowledge that leads to improved outcomes. Although the practice improvement was seen in a limited amount of time, the direction was progressive, foretelling beneficial outcomes when these kinds of quality improvement projects are implemented.
Download or read book Improving Nursing Documentation While Emphasizing the Importance of Comprehensive Charting on the Removal of Intravascular Devices written by Carly Jane Wells and published by . This book was released on 2017 with total page 32 pages. Available in PDF, EPUB and Kindle. Book excerpt: Background: Healthcare documentation not only allows for communication among healthcare providers and maintains patient care record keeping, it also archives essential information used to track, evaluate, and consider valuable healthcare interventions. When documented properly, this information can be used in research to assess international and national healthcare topics like standards of care, quality of care, complication and infection rates, and many more. When documentation is not complete ad comprehensive, a false representation can be made and a patient's safety is at risk. The American Nurse Association suggests nursing documentation be clear, accurate, complete, and accessible, allowing nurses to be responsible and held accountable for their documentation. Foreground: The inpatient unit of interest for this project, like many other hospital units, demands several hours of direct patient care, potentially leaving little time for complete documentation. As a consequence, documenting on important aspects of a patient's record, like the removal of any intravenous device (IVD), are missed or incomplete. When these pieces of information are missing, opportunities to provide accurate data regarding patients, fall short. Therefore, it was this project's objective to influence staff nurses to be as comprehensive as possible when documenting overall, and to see an improvement on the removal of any IVD documentation after providing an educational in-service. Theoretical and EBP Support: Lewin's Change Theory served as a supporting component in influencing and guiding the nurses of interest, transforming their care and making it a standard of practice when documenting on the removal of IVDs. In supporting this project's development, the Johns Hopkins Nursing Evidence-Based-Practice (EBP) Model served as guiding feature in the specific steps of EBP in nursing. Methods: Once both Institutional Review Boards granted approval for this Quality Improvement project, chart audits were performed within a three-week time frame pre- and post- nurse in-service. The provided in-service was given to staff nurses, float pool nurses, and nursing students over an 11-day period. The in-service included pertinent aspects of documentation, steps to improve current practice, which was supported by current evidence, and time for discussion regarding potential barriers to complete documentation. Findings: A clinically significant improvement of 11% was seen in comprehensive documentation on the removal of IVDs on a specific surgical patient population. The findings of this project predictively aligned with literature that supports the use of health information technology, like the electronic health record, were data are accurately and efficiently collected, which can be used to generate knowledge that leads to improved outcomes. Although the practice improvement was seen in a limited amount of time, the direction was progressive, foretelling beneficial outcomes when these kinds of quality improvement projects are implemented.
Author: Elizabeth I Gonzalez, RN, Bs
Publisher: Hcpro, a Division of Simplify Compliance
Published: 2014-11-26
Total Pages: 0
ISBN-13: 9781556452314
DOWNLOAD EBOOKClinical Documentation Strategies for Home HealthElizabeth I. Gonzalez, RN, BSN Are you looking for training assistance to help your homecare staff enhance their patient assessment documentation skills? Look no further than Clinical Documentation Strategies for Home Health. This go-to resource features home health clinical documentation strategies to help agencies provide quality patient care and easily achieve regulatory compliance by: Efficiently and effectively training staff to perform proper patient assessment documentation Helping nurses and clinicians understand the importance of accurate documentation to motivate improvement efforts Reducing reimbursement issues and liability risks to address financial and legal concerns This comprehensive resource covers everything homecare providers need to know regarding documentation best practices, including education for staff training, guidance for implementing accurate patient assessment documentation, tips to minimize legal risks, steps to develop foolproof auditing and documentation systems, and assistance with quality assurance and performance improvement (QAPI) management. Clinical Documentation Strategies for Home Health provides: Forms that break down the functions and documentation requirements of the clinical record by Conditions of Participation, Medicare, and PI activities Tips for coding OASIS Examples of legal issues such as negligence Case studies and advice for managing documentation risk (includes a checklist) Comprehensive documentation and auditing tools that can be downloaded and customized Table of Contents: Key aspects of documentation Defensive documentation: Reduce risk and culpability Contemporary nursing practice Clinical documentation Nursing negligence: Understanding your risks and culpability Improving your documentation Developing a foolproof documentation system Auditing your documentation system Telehealth and EHR in homecare Motivating yourself and others to document completely and accurately
Download or read book Clinical Documentation Strategies for Home Health written by Elizabeth I Gonzalez, RN, Bs and published by Hcpro, a Division of Simplify Compliance. This book was released on 2014-11-26 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: Clinical Documentation Strategies for Home HealthElizabeth I. Gonzalez, RN, BSN Are you looking for training assistance to help your homecare staff enhance their patient assessment documentation skills? Look no further than Clinical Documentation Strategies for Home Health. This go-to resource features home health clinical documentation strategies to help agencies provide quality patient care and easily achieve regulatory compliance by: Efficiently and effectively training staff to perform proper patient assessment documentation Helping nurses and clinicians understand the importance of accurate documentation to motivate improvement efforts Reducing reimbursement issues and liability risks to address financial and legal concerns This comprehensive resource covers everything homecare providers need to know regarding documentation best practices, including education for staff training, guidance for implementing accurate patient assessment documentation, tips to minimize legal risks, steps to develop foolproof auditing and documentation systems, and assistance with quality assurance and performance improvement (QAPI) management. Clinical Documentation Strategies for Home Health provides: Forms that break down the functions and documentation requirements of the clinical record by Conditions of Participation, Medicare, and PI activities Tips for coding OASIS Examples of legal issues such as negligence Case studies and advice for managing documentation risk (includes a checklist) Comprehensive documentation and auditing tools that can be downloaded and customized Table of Contents: Key aspects of documentation Defensive documentation: Reduce risk and culpability Contemporary nursing practice Clinical documentation Nursing negligence: Understanding your risks and culpability Improving your documentation Developing a foolproof documentation system Auditing your documentation system Telehealth and EHR in homecare Motivating yourself and others to document completely and accurately
Author: Gloria M. Bulechek, PhD, RN, FAAN
Publisher: Elsevier Health Sciences
Published: 2012-11-01
Total Pages: 638
ISBN-13: 0323100112
DOWNLOAD EBOOKCovering the full range of nursing interventions, Nursing Interventions Classification (NIC), 6th Edition provides a research-based clinical tool to help in selecting appropriate interventions. It standardizes and defines the knowledge base for nursing practice while effectively communicating the nature of nursing. More than 550 nursing interventions are provided - including 23 NEW labels. As the only comprehensive taxonomy of nursing-sensitive interventions available, this book is ideal for practicing nurses, nursing students, nursing administrators, and faculty seeking to enhance nursing curricula and improve nursing care. More than 550 research-based nursing intervention labels with nearly 13,000 specific activities Definition, list of activities, publication facts line, and background readings provided for each intervention. NIC Interventions Linked to 2012-2014 NANDA-I Diagnoses promotes clinical decision-making. New! Two-color design provides easy readability. 554 research-based nursing intervention labels with nearly 13,000 specific activities. NEW! 23 additional interventions include: Central Venous Access Device Management, Commendation, Healing Touch, Dementia Management: Wandering, Life Skills Enhancement, Diet Staging: Weight Loss Surgery, Stem Cell Infusion and many more. NEW! 133 revised interventions are provided for 49 specialties, including five new specialty core interventions. NEW! Updated list of estimated time and educational level has been expanded to cover every intervention included in the text.
Download or read book Nursing Interventions Classification (NIC) written by Gloria M. Bulechek, PhD, RN, FAAN and published by Elsevier Health Sciences. This book was released on 2012-11-01 with total page 638 pages. Available in PDF, EPUB and Kindle. Book excerpt: Covering the full range of nursing interventions, Nursing Interventions Classification (NIC), 6th Edition provides a research-based clinical tool to help in selecting appropriate interventions. It standardizes and defines the knowledge base for nursing practice while effectively communicating the nature of nursing. More than 550 nursing interventions are provided - including 23 NEW labels. As the only comprehensive taxonomy of nursing-sensitive interventions available, this book is ideal for practicing nurses, nursing students, nursing administrators, and faculty seeking to enhance nursing curricula and improve nursing care. More than 550 research-based nursing intervention labels with nearly 13,000 specific activities Definition, list of activities, publication facts line, and background readings provided for each intervention. NIC Interventions Linked to 2012-2014 NANDA-I Diagnoses promotes clinical decision-making. New! Two-color design provides easy readability. 554 research-based nursing intervention labels with nearly 13,000 specific activities. NEW! 23 additional interventions include: Central Venous Access Device Management, Commendation, Healing Touch, Dementia Management: Wandering, Life Skills Enhancement, Diet Staging: Weight Loss Surgery, Stem Cell Infusion and many more. NEW! 133 revised interventions are provided for 49 specialties, including five new specialty core interventions. NEW! Updated list of estimated time and educational level has been expanded to cover every intervention included in the text.
