| Preface |
|
ix | |
| Acknowledgments |
|
xiii | |
| PART I: COMMUNICATIONS IN NURSING PRACTICE |
|
|
Introduction to Documentation, Liability, and Nursing Practice |
|
|
3 | (12) |
|
|
|
|
|
|
Current Approaches in Charting |
|
|
15 | (14) |
|
|
|
|
|
|
Computer-Based Patient Records |
|
|
29 | (12) |
|
|
|
|
|
|
Common Problems of Recording in the Medical Record |
|
|
41 | (12) |
|
|
|
|
|
|
Issues Requiring Reporting and Recording |
|
|
53 | (12) |
|
|
|
|
|
|
|
|
|
|
|
Reporting Health and Safety Issues |
|
|
65 | (10) |
|
|
|
|
|
| PART II: THE BASIS FOR LIABILITY |
|
|
Nursing Negligence Issues |
|
|
75 | (16) |
|
|
|
|
|
|
Risk Management and Claims Prevention |
|
|
91 | (12) |
|
|
|
|
|
| PART III: DOCUMENTATION IN PRACTICE SETTINGS |
|
|
Staffing and Delegation of Patient Care |
|
|
103 | (12) |
|
|
|
|
|
|
|
|
|
|
|
Recording Patient Care in the Emergency Department |
|
|
115 | (12) |
|
|
|
|
|
|
Recording Patient Care in the Critical Care Unit |
|
|
127 | (8) |
|
|
|
|
|
|
Recording Patient Care in the Obstetric Unit |
|
|
135 | (10) |
|
|
|
|
|
|
Recording Patient Care in the Pediatric Unit |
|
|
145 | (8) |
|
|
|
|
|
|
Recording Patient Care in Perioperative Nursing |
|
|
153 | (22) |
|
|
|
|
|
|
|
|
|
|
|
Recording Patient Care in Psychiatric/Mental Health Nursing |
|
|
175 | (8) |
|
|
|
|
|
|
Communications in Community and Home Health Care Nursing |
|
|
183 | (14) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Documentation in Extended and Long-Term Care Nursing |
|
|
197 | (14) |
|
|
|
|
|
|
Advanced Practice Nursing Issues |
|
|
211 | (12) |
|
|
|
|
|
|
|
|
|
|
|
Nursing Educators, Administration, and Nursing Education |
|
|
223 | (18) |
|
|
|
|
|
|
|
|
241 | (8) |
|
|
|
|
|
| PART IV: A NATIONAL HEALTH INFORMATION SYSTEM FOR THE 21st CENTURY |
|
|
Dialogue for a National Health Information System |
|
|
249 | (8) |
|
|
|
|
|
|
|
|
|
|
| Appendix A: Samples |
|
257 | (8) |
|
Collaborative Practice Agreement |
|
|
257 | (1) |
|
|
|
258 | (2) |
|
Nurse Practitioner/Physician Collaborative Practice Agreement |
|
|
260 | (5) |
| Apendix B: American Association of Legal Nurse Consulting Chapters (As of 1998) |
|
265 | (4) |
| References |
|
269 | (8) |
| Legal Case References |
|
277 | (2) |
| Glossary |
|
279 | (8) |
| Index |
|
287 | (6) |
| Author and Contributors |
|
293 | |
Other versions by this Author
