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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.
eBook details
- Title: DocuNotes: Clinical Pocket Guide to Effective Charting
- Author : Cherie Rebar RN MSN MBA FNP
- Release Date : *
- Genre: Books,New, Used & Rental Textbooks,Medicine & Health Sciences
- Pages : * pages
- Size : * KB
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