Synopsis
Clinical documentation can significantly affect a nursing home's survey results, reimbursement received, and most importantly, resident care. Yet, little formal training is given on how to complete this complicated, and often confusing, process. With so much at stake, it's critical that nurses have a resource they can turn to in order to help achieve accurate, comprehensive documentation for all residents.
Clinical Documentation provides a step-by-step approach to ensuring your documentation is complete and accurate, including coverage of: common conditions encountered in long-term care presented in a straightforward, list format, system assessments to help identify problems, all the documentation resources nurses need to use every day. Save time, ease confusion, and avoid the legal implications of improper documentation with Clinical Documentation as your daily guide.
Doody Review Services
Reviewer:Katy T. Nguyen, MSN(University of Missouri-Columbia)
Description:This book outlines the approach to documentation of common clinical conditions for long-term care residents by assessments and interventions.
Purpose:The author provides documentation guidelines that contain useful assessment tools and resources for which nurses are accountable, but may not have committed to memory.
Audience:It is written for licensed nursing staff who work in long-term care settings.
Features:The book contains documentation guidelines by system assessment as well as by clinical condition assessment. It also provides some assessment tools to support the documentation.
Assessment:This is a wonderful reference for nurses on how to document nursing assessments and nursing interventions for common clinical conditions in a nursing home. It serves as a good resource for long-term care providers who investigate causation of clinical condition and system management.