Documentation : essentials of nursing documentation /

"This program describes commonly used approaches to documentation, a review of the basic data to record in patient records, and practice guidelines to follow that protect patient privacy, comply with federal regulations, and protect the nurse against potential legal actions. After completing th...

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Bibliographic Details
Corporate Author: Medcom, inc. Trainex Division
Format: Video DVD
Language:English
Language Notes:Closed captioned.
Published: Cypress, CA : Medcom Trainex, ©2013.
Subjects:
Online Access:Connect to this streaming video
Table of Contents:
  • Functions of medical records
  • Types of documentation
  • Source oriented documentation
  • Problem oriented documentation
  • Focus charting
  • Charting by exception
  • Case management documentation
  • Process of documentation
  • .Documentation of data collected
  • Caveats
  • Special circumstances: verbal orders
  • Legal aspects of documentation.