This handbook offers a thorough overview of nursing documentation, and its importance, within the context of the nursing process. Users learn the principles of effective documentation and methods of documenting and examine trends relevant to this aspect of nursing care. Example forms are included to provide readers with hands-on experience with the documentation format.
UNIT 1: NURSING PROCESS.
Chapter 1: Nursing Process.
Chapter 2: Assessment.
Chapter 3: Diagnosis.
Chapter 4: Planning And Outcome Identification.
Chapter 5: Implementation.
Chapter 6: Evaluation.
UNIT 2: DOCUMENTATION
Chapter 7: Documentation As Communication.
Chapter 8: Principles Of Effective Documentation.
Chapter 9: Methods Of Documentation.
Chapter 10: Forms For Recording Data.
Chapter 11: Trends In Documentation.
Chapter 12: Reporting.
Appendix A: Nanda Nursing Diagnoses.
Appendix B: Glossary.
Appendix C: Abbreviations and Acronyms.
Appendix D: Answers to Review Questions