Surefire documentation : how, what, and when nurses need to document.
- St. Louis ; Toronto : Mosby, Inc., c1999.
- ix, 325 p. : ill. ; 23 cm.
Contents;
Part 1: Caring for patients When you perform your initial patient assessment When your patient loses a peripheral pulse When your patient has chest pain When your patient has a myocardial infarction When your patient has heart failure When your patient is in shock When your patient has cardiopulmonary arrest When your patient has pneumonia When your patient has an asthma attack When your patient has pulmonary embolism When your patient has pulmonary edema etc.
Part 2: Dealing with challenging situations When your patient documents her own care When your patient asks to see his medical record When your patient's medical record isn't available When your patient withholds his medical history When your patient refuses treatment When your patient is noncompliant When your patient is in police custody When your patient leaves against medical advice When your patient threatens to sue When your patient makes a sexual advance etc.
Part 3: Handling difficult professional problems When a physician or colleague illegally alters the medical record When a colleague criticizes your care in the medical record When you find an inappropriate comment in the medical record When a physician asks to remove a medical record from the facility How to handle a physician's questionable order When you take a telephone or verbal order When a physician's order is illegible When a colleague asks you to document her care When a coworker gives your patient drugs in your absence When you suspect that a colleague is negligent etc.