This introductory text covers the basics of all forms of nursing documentation, including concepts and application. The focus is on communication as the key to documentation, whether written or oral. This important learning tool contains many examples of actual documentation, practice sessions at the end of each chapter, and Challenge for Critical Thinking and Learning to Document sections that encourage the reader to analyze, synthesize and apply what they have learned. Also discussed are issues in the documentation of nursing care delivery such as critical pathways, case management and computerized charting.A problem-oriented medical sample is shown below to differentiate it from a nursing problem-oriented sample. Case example: ... With SOAP notes, additional components that reflect the nursing process are presented in the note. SOAP Notesanbsp;...
|Author||:||Ellen Thomas Eggland|
|Publisher||:||Lippincott Williams & Wilkins - 1994|