Documentation Skills For Quality Patient Care
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Documentation Skills For Quality Patient Care
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Author : Fay Yocum
language : en
Publisher:
Release Date : 1999
Documentation Skills For Quality Patient Care written by Fay Yocum and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 1999 with Medical categories.
Documentation Skills For Quality Patient Care
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Author : Fay Yocum
language : en
Publisher:
Release Date : 1994-09-01
Documentation Skills For Quality Patient Care written by Fay Yocum and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 1994-09-01 with categories.
Clinical Documentation Strategies For Home Health
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Author : Elizabeth I Gonzalez, RN, Bs
language : en
Publisher: Hcpro, a Division of Simplify Compliance
Release Date : 2014-11-26
Clinical Documentation Strategies For Home Health written by Elizabeth I Gonzalez, RN, Bs and has been published by Hcpro, a Division of Simplify Compliance this book supported file pdf, txt, epub, kindle and other format this book has been release on 2014-11-26 with categories.
Clinical Documentation Strategies for Home HealthElizabeth I. Gonzalez, RN, BSN Are you looking for training assistance to help your homecare staff enhance their patient assessment documentation skills? Look no further than Clinical Documentation Strategies for Home Health. This go-to resource features home health clinical documentation strategies to help agencies provide quality patient care and easily achieve regulatory compliance by: Efficiently and effectively training staff to perform proper patient assessment documentation Helping nurses and clinicians understand the importance of accurate documentation to motivate improvement efforts Reducing reimbursement issues and liability risks to address financial and legal concerns This comprehensive resource covers everything homecare providers need to know regarding documentation best practices, including education for staff training, guidance for implementing accurate patient assessment documentation, tips to minimize legal risks, steps to develop foolproof auditing and documentation systems, and assistance with quality assurance and performance improvement (QAPI) management. Clinical Documentation Strategies for Home Health provides: Forms that break down the functions and documentation requirements of the clinical record by Conditions of Participation, Medicare, and PI activities Tips for coding OASIS Examples of legal issues such as negligence Case studies and advice for managing documentation risk (includes a checklist) Comprehensive documentation and auditing tools that can be downloaded and customized Table of Contents: Key aspects of documentation Defensive documentation: Reduce risk and culpability Contemporary nursing practice Clinical documentation Nursing negligence: Understanding your risks and culpability Improving your documentation Developing a foolproof documentation system Auditing your documentation system Telehealth and EHR in homecare Motivating yourself and others to document completely and accurately
Nursing Documentation In Aged Care
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Author : Christine Crofton
language : en
Publisher:
Release Date : 2004
Nursing Documentation In Aged Care written by Christine Crofton and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2004 with Medical categories.
As another volume in Ausmed's 'Guide to Practice' series of textbooks and audiobooks, this is an essential text for all aged-care nurses who wish to enhance their documentation skills and deliver higher quality care to the elderly. AudioBooks are ideal teaching tools.
Nursing Documentation Made Incredibly Easy
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Author : Kate Stout
language : en
Publisher: Lippincott Williams & Wilkins
Release Date : 2018-06-05
Nursing Documentation Made Incredibly Easy written by Kate Stout and has been published by Lippincott Williams & Wilkins this book supported file pdf, txt, epub, kindle and other format this book has been release on 2018-06-05 with Medical categories.
Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more. Whether you are a nursing student or a new or experienced nurse, this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely, accurate, and watertight. Let the experts walk you through up-to-date best practices for nursing documentation, with: NEW and updated, fully illustrated content in quick-read, bulleted format NEWdiscussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices Easy-to-read, easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations, while addressing the different styles of charting Outlines the Do's and Don’ts of charting – a common sense approach that addresses a wide range of topics, including: Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation Documenting the patient’s health history and physical examination The Joint Commission standards for assessment Patient rights and safety Care plan guidelines Enhancing documentation Avoiding legal problems Documenting procedures Documentation practices in a variety of settings—acute care, home healthcare, and long-term care Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior Special features include: Just the facts – a quick summary of each chapter’s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans “Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.
Clinical Documentation Specialist The Comprehensive Guide
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Author : VIRUTI SHIVAN
language : en
Publisher: Viruti Satyan Shivan
Release Date :
Clinical Documentation Specialist The Comprehensive Guide written by VIRUTI SHIVAN and has been published by Viruti Satyan Shivan this book supported file pdf, txt, epub, kindle and other format this book has been release on with Medical categories.
Dive into the essential world of clinical documentation with "Clinical Documentation Specialist - The Comprehensive Guide," a pivotal resource designed for healthcare professionals committed to excellence in patient care through meticulous record-keeping. This guide offers a deep dive into the principles of accurate and compliant medical documentation, highlighting its critical role in ensuring optimal patient outcomes and the seamless operation of healthcare systems. With an emphasis on practical strategies, real-world applications, and the latest compliance standards, this book serves as an invaluable tool for both aspiring and experienced clinical documentation specialists. By focusing on enhancing communication between healthcare providers and supporting the delivery of high-quality care, it addresses the challenges and complexities of modern medical documentation practices. Without relying on images or illustrations for clarity, the guide stands out for its comprehensive coverage and insightful analysis, making it a unique addition to the professional library of healthcare providers. It transcends basic instructional material by weaving in theoretical knowledge with actionable advice, empowering readers to navigate the nuanced landscape of healthcare documentation with confidence. The absence of visual elements is more than compensated for by the depth of knowledge and the engaging writing style, ensuring that readers are equipped with the knowledge and skills necessary to make a significant impact in their roles as guardians of patient information and care continuity.
Handbook Of Home Health Standards E Book
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Author : Tina M. Marrelli
language : en
Publisher: Elsevier Health Sciences
Release Date : 2008-10-13
Handbook Of Home Health Standards E Book written by Tina M. Marrelli and has been published by Elsevier Health Sciences this book supported file pdf, txt, epub, kindle and other format this book has been release on 2008-10-13 with Medical categories.
Handbook of Home Health Standards: Quality, Documentation, and Reimbursement includes everything the home care nurse needs to provide quality care and effectively document care based on accepted professional standards. This handbook offers detailed standards and documentation guidelines including ICD-9-CM (diagnostic) codes, OASIS considerations, service skills (including the skills of the multidisciplinary health care team), factors justifying homebound status, interdisciplinary goals and outcomes, reimbursement, and resources for practice and education. The fifth edition of this “little red book has been updated to include new information from the most recently revised Federal Register Final Rule and up-to-date coding. All information in this handbook has been thoroughly reviewed, revised, and updated. Offers easy-to-access and easy-to-read format that guides users step by step through important home care standards and documentation guidelines Provides practical tips for effective documentation of diagnoses/clinical conditions commonly treated in the home, designed to positively influence reimbursement from third party payors. Lists ICD-9-CM diagnostic codes, needed for completing CMS billing forms, in each body system section, along with a complete alphabetical list of all codes included in the book in an appendix. Incorporates hospice care and documentation standards so providers can create effective hospice documentation. Emphasizes the provision of quality care by providing guidelines based on the most current approved standards of care. Includes the most current NANDA-approved nursing diagnoses so that providers have the most accurate and up-to-date information at their fingertips. Identifies skilled services, including services appropriate for the multidisciplinary team to perform. Offers discharge planning solutions to address specific concerns so providers can easily identify the plan of discharge that most effectively meets the patient’s needs. Lists the crucial parts of all standards that specific members of the multidisciplinary team (e.g., the nurse, social worker) must uphold to work effectively together to achieve optimum patient outcomes. Resources for care and practice direct providers to useful sources to improve patient care and/or enhance their professional practice. Each set of guidelines includes patient, family, and caregiver education so that health care providers can supply clients with necessary information for specific problems or concerns. Communication tips identify quantifiable data that assists in providing insurance case managers with information on which to make effective patient care decisions. Several useful sections make the handbook thorough and complete: medicare guidelines; home care definitions, roles, and abbreviations; NANDA-approved nursing diagnoses; guidelines for home medial equipment and supplies. Small size for convenient carrying in bag or pocket! Provides the most up-to-date information about the newest and predominant reimbursement mechanisms in home care: the Prospective Payment System (PPS) and Pay For Performance (P4P). Updated terminology, definitions, and language to reflect the federal agency change from Health Care Financing Administration (HCFA) to Centers for Medicare & Medicaid Services (CMS) and other industry changes. Includes the most recent NANDA diagnoses and OASIS form and documentation explanations. New interdisciplinary roles have been added, such as respiratory therapist and nutritionist.,/LI>
Documenting Care
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Author : Frances Talaska Fischbach
language : en
Publisher: F. A. Davis Company
Release Date : 1991
Documenting Care written by Frances Talaska Fischbach and has been published by F. A. Davis Company this book supported file pdf, txt, epub, kindle and other format this book has been release on 1991 with Medical categories.
University of Wisconsin-Milwaukee School of Nursing's comprehensive charting and documentation manual for students and practitioners.
Legal Aspects Of Documenting Patient Care For Rehabilitation Professionals
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Author : Ronald W. Scott
language : en
Publisher: Jones & Bartlett Learning
Release Date : 2006
Legal Aspects Of Documenting Patient Care For Rehabilitation Professionals written by Ronald W. Scott and has been published by Jones & Bartlett Learning this book supported file pdf, txt, epub, kindle and other format this book has been release on 2006 with Medical care categories.
Because communication among health care professionals can mean the difference between patient life and death, clear and effective patient care documentation is as important as the delivery of care itself. The rehabilitation professional faces formidable documentation responsibilities. Patient care documentation created by the rehabilitation professional must be accurate, comprehensive, concise, objective, and timely. In an interdisciplinary health care environment, documentation must also be expeditiously communicated to other professionals on the health care team.
Nursing Interventions Clinical Skills E Book
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Author : Anne Griffin Perry
language : en
Publisher: Elsevier Health Sciences
Release Date : 2011-05-05
Nursing Interventions Clinical Skills E Book written by Anne Griffin Perry and has been published by Elsevier Health Sciences this book supported file pdf, txt, epub, kindle and other format this book has been release on 2011-05-05 with Medical categories.
With its new condensed format, completely reorganized and updated content, respected author team, and new lower price, Perry and Potter's Nursing Interventions and Clinical Skills, 5th Edition is your all-around best choice for learning the skills and techniques you'll use every day in practice. Covering 181 skills, this highly accessible manual conveniently groups all related skills together, so you can find information quickly. The companion Evolve website features 50 video clips, skills checklists, and much more, ensuring your successful mastery of each skill. Contains 180 skills and techniques (basic, intermediate, and advanced) you'll use every day in practice. Presents every skill in a logical, consistent format: Assessment, Planning, Implementation, Evaluation -- improving the quality of patient care. Pairs each step with an appropriate rationale, helping you understand and remember why specific techniques are used. Features Safety Alerts that highlight unusual risks inherent in the next step of the skill, helping you plan ahead at each step of nursing care. Uses a Glove icon as a reminder to don clean gloves before proceeding to the next step of the skill, improving patient safety. Guides you in Delegation and Collaboration, explaining when to delegate a skill to assistive personnel, and indicating what key information must be shared. Highlights Special Considerations such as information unique to pediatric or geriatric patients, to raise awareness of additional risks you may face when caring for a diverse patient population. Provides sample documentation of nurses notes so that you can learn to communicate effectively to the patient care team. Contains multimedia resources such as video clips, skills performance checklists, interactive exercises, and more, all easily available to you on the companion Evolve website at no additional cost. Content has been reorganized to make topics easier to find, improving ease of use. Covers new topics that will help you develop the skills needed to practice according to the TJC and ACCN recommendations. Covers new skills that will prepare you for nursing practice in a wide variety of environments. Features a unique new chapter, Using Evidence in Practice, that introduces you to using evidence to solve clinical problems. Introduces you to Consistent Patient Identification Protocol as recommended by The Joint Commission, improving quality of care and patient safety. Includes enhanced and greatly expanded end-of-chapter exercises, now featuring case study questions, NCLEX alternate format questions, and multiple-choice questions.