DocuNotes Clinical Pocket Guide to Effective

A Daviss Notes Book. The perfect pocket guide for charting; ensures that documentation is not only complete and thorough, but also meets the highest ethical and legal standards. Covers nuances that are relevant to various specialties, including pediatric, OB/GYN, psychiatric and outpatient nursing. Reviews terminology essential to communicate effectively in writing with doctors, other health care professionals, and staff. Includes how-tos for template, electronic and other forms of charting.

TAB 1 Terminology
TAB 2 Types of Charting
TAB 3 Basic Documentation
TAB 4 Documentation of Standard Assessments/
History and Review of Systems
TAB 5 Documentation of Standard Assessments/Medical, Social & Family Histories
TAB 6 Documentation of Physical Assessment
TAB 7 Documentation of Nursing Skills, Procedures, and Medication Administration
TAB 8 Documentation of Nuances within Specialized Fields
TAB 9 Nuances Associated with Template Charting, Electronic Charting
TAB 10 Legal and Ethical Issues

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DocuNotes Clinical Pocket Guide to Effective Charting

Summary

Table of Contents

Supplemental Materials