Clinical Documentation
An Essential Guide for Long-Term Care Nurses
Barbara Acello
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Product Description:
A revolutionary clinical resource for long-term care nurses!
Struggling to create clinical documentation to describe residents’ conditions every day? Poor clinical documentation can significantly affect survey results, reimbursement received, and most importantly, resident care. And improper documentation in the medical record has landed plenty of facilities in hot water when used as evidence in a lawsuit.
Document your residents’ care confidently, with an expert resource by your side.
Written by accomplished author and industry expert, Barbara Acello, RN, BSN, Clinical Documentation: An Essential Guide for Long-Term Care offers a unique, systematic approach to documentation and charting. You’ll not only save time, but achieve accurate, comprehensive documentation for every resident in your care.
The book’s revolutionary approach to long-term care clinical documentation means all the common conditions encountered in long-term care are at your fingertips, including:
- 24 Hour Change of Condition
- Acute Pulmonary Infection, Acute Exacerbation COPD
- Anticoagulant Drug Therapy
- Autonomic Dysreflexia
- Behavior Change
- Blood Clots
- Cerebrovascular Accident (CVA)
- Chemotherapy
- Chest Pain
- Compartment Syndrome
- Congestive Heart Failure (CHF)
- Constipation, Fecal Impaction
- Death of Resident
- Dehydration, Actual or Risk for
- Diabetic Residents, Observations of
- Discharge
- Dysphagia
- Edema
- Falls
- Fractures
- Gastrointestinal Upset, Distress, Other Related Conditions
- Head Injury, Suspected Head Injury, or Unwitnessed Fall
- Head Injury/Potential Subdural Hematoma
- Herpes Zoster
- Hip fracture, replacement, or related injury
- Hypertension
- Illness, General Signs and Symptoms (Unknown Etiology)
- Incident Report
- Infection, General Signs/Symptoms of (Unknown Etiology)
- Myocardial Infarction
- Pain (Etiology Known or Unknown)
- Pain Assessment
- Pain, Nursing responsibilities for managing
- Peripheral Vascular Disease - Leg Ulcer Comparison
- Pressure Ulcer
- Radiation therapy
- Renal Failure, Acute - Prerenal Azotemia
- Renal Failure, Chronic - Residents Receiving Dialysis Treatment for ESRD
- Restraint Order (New)
- Scabies
- Seizure Activity
- Sepsis, Urosepsis
- Skin Tear Assessment and Classification
- Telephone Orders
- Temperature, Abnormalities Related to Temperature Regulation
- Tracheostomy, Resident with a
- Transient Ischemic Attack (TIA)
- Unstable or Postoperative Resident Observations
- Urinary Tract Infection and Genitourinary Disorders
- UTI, Signs and Symptoms in Cognitive Impairment
- Weight loss, Cachexia, Malnutrition
You’ll also benefit from assessment and documentation guidelines by system to help identify problems, enteral and parenteral nutrition, and observations and relevant documentation of ADLs.
Save time, ease confusion, and avoid the legal implications of improper documentation with Clinical Documentation as your daily guide. Order today!
Product Types : Departments :
SOURCE CODE: ECMW
ISBN: 978-1-57839-950-5
PUBLISHED: 01/18/2007
