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Name: Document Smart | The A-to-Z Guide to Better Nursing Documentation
Brand: Wolters Kluwer Health
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The A-to-Z Guide to Better Nursing Documentation

Theresa Capriotti(Autor*in)

Wolters Kluwer Health (Verlag)

1. Auflage

Erschienen am 26. Juni 2019

512 Seiten

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978-1-9751-2074-0 (ISBN)

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Beschreibung

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Inhalt

Intro
Title Page
Copyright Page
Contents
Computerized and Electronic Health Records
Safe Medication Administration and Use of Barcodes on Medications
A
Abuse, Suspected
Activities of Daily Living
Advance Directive
Advice to Patient by Telephone
Against Medical Advice, Discharge
Against Medical Advice, Out of Bed
Alcohol Found at Bedside
Allergy Testing
Anaphylaxis
Arrhythmias
Arterial Blood Sampling
Arterial Line Insertion
Arterial Line Removal
Arterial Occlusion, Acute
Arterial Pressure Monitoring
Arthroplasty Care
Aspiration, Foreign Body
Aspiration, Tube Feeding
Assessment, Initial
Asthma
B
Bladder Irrigation, Continuous
Blank Spaces in Chart or Flow Sheet
Blood Transfusion
Blood Transfusion Reaction
Bone Marrow Aspiration and Biopsy
Brain Death
Burns, Assessment and Nursing Care
C
Cardiac Monitoring (Telemetry)
Cardiac Tamponade
Cardiopulmonary Arrest and Resuscitation
Cardioversion, Synchronized
Caregiver Strain
Care Plan, Traditional
Cast Care
Central Venous Access Device Insertion
Central Venous Access Device Occlusion
Central Venous Access Device Removal
Central Venous Access Device Site Care
Central Venous Pressure Monitoring
Chest Pain
Chest Tube Care
Chest Tube Insertion
Chest Tube Removal
Chest Tube Removal by Patient
Clinical Pathway
Cold Therapy Application
Confusion
Continuous Renal Replacement Therapy
Correction to Documentation
Critical Test Values, Reporting
Cultural Needs Identification
D
Death of a Patient
Dehydration, Acute
Dementia
Diabetic Ketoacidosis
Discharge Instructions
Do-Not-Resuscitate Order
Computerized Physician Order Entry (Formerly Called Doctor's Orders)
Health Care Provider's Orders, Telephone
Health Care Provider's Orders, Verbal
Drug Administration
Drug Administration, Adverse Effects of
Drug Administration, One-Time Dose
Drug Administration, Opioid
Drug Administration, Stat Order
Drug Administration, Withholding Ordered Drug
Drugs, Illegal
Drugs, Inappropriate Use of
Drugs, Patient Hiding
Drugs, Patient Refusal to Take
Dyspnea
E
Elopement from a Health Care Facility
Emergency Treatment, Patient Refusal of
End-of-Life Care
Endotracheal Extubation
Endotracheal Intubation
Endotracheal Tube, Patient Removal of
End-Tidal Carbon Dioxide Monitoring
Enema Administration
Epidural Analgesia
Epidural Hematoma
Esophageal Tube Insertion (Sengstaken-Blakemore Tube)
Esophageal Tube Removal
Experimental Procedures
F
Failure to Provide Information
Falls, Patient
Falls, Precautions
Falls, Visitor or Other
Firearms at Bedside
Firearms in the Home
Firearms on Family Member or Visitor
G
Gastric Lavage
Gastrointestinal Hemorrhage
H
Health Insurance Portability and Accountability Act
Hearing Impairment
Heart Failure, Daily Assessment
Heat Therapy
Hemodynamic Monitoring
Home Care, Home Care Aide Needs
Home Care, Initial Assessment
Home Care, Interdisciplinary Communication in
Home Care, Patient-Teaching Certification in
Home Care Certification and Care Plan
Home Care Discharge Summary
Home Care Progress Notes
Home Care Recertification
Home Care Referral
Home Care Telephone Orders
Hyperglycemia
Hyperosmolar Hyperglycemic Nonketotic Syndrome
Hypertensive Crisis
Hyperthermia-Hypothermia Blanket
Hypoglycemia
Hypotension
Hypovolemia
Hypoxemia
IJK
Illegal Alteration of a Medical Record
Implanted Port, Accessing
Implanted Port, Care of
Implanted Port, Withdrawing Access
Inappropriate Comment in the Medical Record
Incident Report
Increased Intracranial Pressure
Infection Control
Informed Consent, Inability to Give
Informed Consent in Emergency Situation
Informed Consent, Lack of Understanding of
Informed Consent When Patient is a Minor
Intake and Output
Intestinal Obstruction
Intra-Aortic Balloon Counterpulsation Care
Intra-Aortic Balloon Insertion
Intra-Aortic Balloon Removal
Intracerebral Hemorrhage
Intracranial Pressure Monitoring
Intravenous Catheter Complication: Cannula Dislodgment
Intravenous Catheter Complication: Phlebitis
Intravenous Catheter Insertion
Intravenous Catheter Removal
Intravenous Site Care
Intravenous Site Change
Intravenous Site Infiltration
Intravenous Therapy, Continuous
L
Language Difficulties
Last Will and Testament, Patient Request for Witness of
Late-Documentation Entry
Latex Hypersensitivity
Level of Consciousness, Changes in
Lumbar Puncture
M
Mechanical Ventilation
Medical Advice, Patient or Family Request for
Medication Error
Medications, Reconciling
Misuse of Equipment
Mixed Venous Oxygen Saturation Monitoring
Moderate Sedation
Multiple Trauma
Myocardial Infarction, Acute
N
Nasogastric Tube Care
Nasogastric Tube Insertion
Nasogastric Tube Removal
Newborn Identification
Patient Nonadherence to Recommended Medical Care
O
Organ Donation
Ostomy Care
Overdose, Drug
Oxygen Administration
P
Pacemaker, Care of Permanent
Pacemaker, Care of Transcutaneous
Pacemaker, Care of Transvenous
Pacemaker, Initiation of Transcutaneous
Pacemaker, Insertion of Permanent
Pacemaker, Insertion of Transvenous
Pacemaker Malfunction
Pain Management
Paracentesis
Parenteral Nutrition Administration, Lipids
Parenteral Nutrition Administration, Total
Patient-Controlled Analgesia
Patient Requesting Access to Medical Records
Patient Self-Documentation of Care
Patient Self-Glucose Testing
Patient Teaching
Patient Teaching, Patient's Refusal of
Patient Threat of Self-Harm
Patient Threat to Harm Another
Patient Transfer to Long-Term Care Facility
Patient Transfer to Specialty Unit
Patient's Belongings, at Admission
Peripherally Inserted Central Catheter Site Care
Peritoneal Dialysis
Peritoneal Dialysis, Continuous Ambulatory
Peritoneal Lavage (Diagnostic Peritoneal Aspiration [DPA])
Peritonitis
Pneumonia
Pneumothorax
Poisoning
Postoperative Care
Preoperative Care
Pressure Ulcer (Pressure Injury) Assessment
Pressure Ulcer (Pressure Injury) Care
Psychosis, Acute
Pulmonary Edema
Pulmonary Embolism
Pulse Oximetry
Q
Quality of Care, Family Questions About
R
Rape-Trauma Syndrome
Refusal of Treatment
Acute Kidney Injury
Reports to Health Care Provider
Respiratory Arrest
Respiratory Distress
Restraints
S
SBAR
Seclusion
Seizure Management
Shock
Sickle Cell Crisis
Skin Care
Skin Graft Care
Smoking
SOAP
Spinal Cord Injury
Splint Application
Status Asthmaticus
Status Epilepticus
Stroke
Surgical Amputation Care
Subdural Hematoma
Substance Abuse by Colleague, Suspicion of
Substance Withdrawal
Suicidal Intent
Suicide Precautions
Suicide Prevention Contract
Surgical Incision Care
Surgical Site Identification
Suture Removal
T
Termination of Life Support
Thoracentesis
Thrombolytic Therapy
Tracheostomy Care
Tracheostomy Occlusion
Tracheostomy Suctioning
Tracheostomy Tube Replacement
Tracheotomy
Traction Care, Skeletal
Traction Care, Skin
Transcutaneous Electrical Nerve Stimulation
Transfusion Reaction, Delayed
Transient Ischemic Attack
Tube Feeding (Enteral Feeding)
Tuberculosis
U
Unresponsiveness by Patient
Urinary Catheter Insertion, Indwelling
V
Vagal Maneuvers
Ventricular Assist Device
Violent Patient
Vision Impairment
Vital Signs, Frequent
WXY
Walker Use
Wound Assessment
Wound Care
Wound Dehiscence
Wound Evisceration
Z
Z-Track Injection
Standardized Systems
The Joint Commission Abbreviations to Avoid
Institute for Safe Medication Practices (ISMP) Drug Sound-Alike/Look-Alike Names
Common Charting Mistakes to Avoid
Charting Checkup: When the Nurse is on Trial-How to Protect Oneself
The NANDA International Nursing Diagnoses
Index

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