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DocuNotes: Nurse’s Clinical Pocket Guide to Effective Charting
By
Cherie Rebar, RN, MSN, MBA, FNP, .
ISBN-13: 978-0-8036-2092-6
ISBN-10: 0-8036-2092-6
175 pp.
20 ill.
Soft cover.
©2009
Available now.
$24.95
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A DAVIS’S NOTES BOOK!
The perfect pocket guide to charting!
The popular Davis’s Notes format makes
sure that you always have the information
you need close at hand to ensure your
documentation is not only complete and
thorough, but also meets the highest ethical
and legal standards.
You’ll even find coverage of the nuances
that are relevant to various specialties,
including pediatric, OB/GYN, psychiatric,
and outpatient nursing. And, the very first
Tab reviews the terminology essential to
communicate effectively in writing with
doctors, other health care professionals,
and staff.
It also delivers all of the features that
Davis’s Notes users rely on...concise,
well-organized, easy-to-reference content
in an easy-to-use spiral binding with
waterproof, reusable pages.
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- Reviews the terminology for written
communications with physicians and staff.
- Describe the types of documentation,
including SOAP notes and DART charts.
- Details the documentation of history taking,
including medical, social, and family
history, physical assessments, and systems.
- Covers the documentation of nursing
skills and procedures as well as medication
administration.
- Addresses the documentation required in
specialized fields such as OB/GYN, pediatrics,
psychiatric, and outpatient nursing.
- Includes how-tos for template, electronic,
and other forms of charting.
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TAB 1 Terminology
TAB 2 Types of Charting
TAB 3 Basic Documentation
TAB 4 Documentation of Standard Assessments/
History and Review of Systems
TAB 5 Documentation of Standard Assessments/Medical, Social & Family Histories
TAB 6 Documentation of Physical Assessment
TAB 7 Documentation of Nursing Skills, Procedures, and Medication Administration
TAB 8 Documentation of Nuances within Specialized Fields
TAB 9 Nuances Associated with Template Charting, Electronic Charting
TAB 10 Legal and Ethical Issues
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