The real-life documentation handbook you shouldn’t be without
To document skillfully and minimize your legal risks, you don’t need theories about documentation. You need the hard facts and real life, expert guidance you’ll find in Surefire Documentation.
Practical, easy to understand advice In clear, concise language, Surefire Documentation explains exactly how, what, and when to document for nearly 100 on the job situations.
This fact filled reference provides authoritative, specific information on:
Caring for patients. Describes your care and documentation for patients with conditions that range from cardiopulmonary arrest and severe pain to HIV infection and pressure ulcers.
Dealing with challenging patient situations. Covers your actions and documentation in such situations as when your patient is noncompliant, refuses treatment, makes a sexual advance, or threatens suicide.
Handling difficult professional problems. Guides you through the dilemmas that can put your professional or legal status on the line, such as when a colleague tampers with the medical record, a patient asks you for medical advice, or you decide to withhold patient care.