Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care By Unknown. Mosby's Surefire Documentation: How, What, and When Nurses Need To Document By Brand: Mosby. Chart Smart: The A-to-Z Guide to Better Nursing Documentation By Springhouse (EDT). I downloadd this book a couple of months ago. This book is a great tool. I don't think it is necessarily for new nurses; this is for every nurse who works in a. Nursing Notes the Easy Way and millions of other books are available for site Kindle. This item:Nursing Notes the Easy Way: + Common Nursing Documentation and Communication Templates by Karen Stuart Gelety Spiral-bound $ Start reading Nursing Notes the Easy Way on your.

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Nursing Documentation Book

eBook features: Highlight, take notes, and search in the book; Length: pages; Enhanced Typesetting: Enabled; Page Flip: Enabled; Due to its large file size. Nursing Documentation Handbook: Medicine & Health Science Books @ Mosby's Surefire Documentation: How, What, and When Nurses Need To Document: Medicine & Health Science Books @

In the busy working day of a nurse, with the many urgent demands on your time, you may feel that keeping nursing records is a distraction from the real work of nursing: This cannot be more wrong! Keeping good records is part of the nursing care we give to our patients. It is nearly impossible to remember everything you did and everything that happened on a shift. Without clear and accurate nursing records for each patient, our handover to the next team of nurses will be incomplete. Needless to say, this can affect the wellbeing of patients. In fact, the quality of our record keeping can be a good or bad reflection of the standard of care we give to our patients: Another important consideration is the legal significance of nursing records. If a patient brings a complaint, your nursing records are the only proof that you have fulfilled your duty of care to the patient. According to the law in many countries, if care or treatment due to a patient is not recorded, it can be assumed that it has not happened. Poor record keeping can therefore mean you are found negligent, even if you are sure you provided the correct care - and this may cause you to lose your right to practise. In short, the patient's nursing record provides a correct account of the treatment and care given and allows for good communication between you and your colleagues in the eye care team.

Many nursing students likely will also find useful an accompanying online teaching package that boasts real-world case studies, participatory assignments and course-management offerings. Fluids and Electrolytes Made Incredibly Easy!

Nursing Notes the Easy Way:100+ Common Nursing Documentation and Communication Templates

Notwithstanding the casual tone of the title, the second edition of this popular reference brings a lighthearted yet utterly serious treatment of the fluids and electrolytes that are so critical to life. The chemical mysteries of acids and bases are clearly explained within their clinical contexts, and the many case studies illustrate the immediate consequences of common and not-so-common problems with fluid and electrolyte levels.

Nursing students facing the scientific rigor of physiopathology classes will greatly appreciate the well-organized format that guides newcomers through surprisingly complex ideas with easy-to-understand explanations.

One notable triumph is a remarkably clear explanation of the phenomenon of osmotic diuresis that threatens so many diabetic patients with harmful dehydration, and the book abounds with other such successes. This piece of advice is along the same lines as using correct spelling and grammar in your documentation. If you do computer charting which is increasingly common , write in complete sentences, using a standard font, color and size.

Typing your notes in purple, point font is unprofessional and distracting.

Never use pencil, as this can smudge and is more difficult to read. Correct mistakes appropriately. After all, what are the chances that someone will examine your charting if your patient faces no complications? Probably low.

Nursing documentation

Develop good habits. As you gain experience and confidence, it can be tempting to let the quality of your documentation slip. The statute of limitations for most medical malpractice cases is two years.

This means that, no matter what happened to a patient you cared for or how shoddy your documentation of those events may be , a patient and his or her lawyer would have a very difficult time holding you or other healthcare professionals liable for any oversights or wrongdoing after that time.

A sample nursing assessment form for an Australian residential aged care home. Nursing care plan[ edit ] The nursing care plan NCP is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients.

There are many ways of structuring nursing care plans in correspondence with the different needs of nursing care in different nursing specialties. For example, a nursing care plan in an Australian residential aged care home may be structured with several sections under each care domain such as pain, mobility, lifestyle, nutrition and continence.

Nursing Documentation - Nursing On Point

The information is recorded in free-text style, and various terms are used singly or in combination to name each of the four sections in the formats that are used by a facility during a particular period Figure 3. Figure A sample nursing assessment form for an Australian residential aged care home Figure An example of a nursing care plan in an Australian residential aged care home Progress notes[ edit ] A progress note is the record of nursing actions and observations in the nursing care process.

An example of a nursing care plan in an Australian residential aged care home. Generally, nurses record information with a common format. Figure 4.

Nursing Documentation Made Incredibly Easy

A sample progress note in an Australian residential aged care home. Recording format[ edit ] Paper-based nursing documentation[ edit ] The paper-based nursing documentation has been in place for decades. Client's data are recorded in paper documents.

The information in these documents needs to be integrated for sense-making in a nursing decision. Electronic nursing documentation[ edit ] Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses.

Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving communication and care service delivery.

The common benefits of electronic documentation systems include the improvement of comprehensiveness in documenting the nursing process, the use of standardized language and the recording of specific items about particular client issues and relevance of the message. In addition, electronic systems can improve legibility, dating and signing in nursing records.

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