Written as a 'step-by-step' guide, this book answers all the common questions nurses have about writing their portfolio. Each chapter includes suggested activities and tasks that can be completed and put into a portfolio, so readers can create a portfolio as they go.
I. Fundamentals: 1.Nursing documentation and the medical record ; 2.Legal and ethical implications of documentation ; 3.Performance improvement and reimbursement ; 4.Documentation systems ; 5.Documentation of the nursing process. II.Documentation for every practice setting: 6.Documentation in acute care ; 7.Documentation in long-term care ; 8.Documentation in home health care ; 9.Documentation in ambulatory care. III.Documentation in action: 10.Documentation of everyday events ; 11.Documentation of selected clinical specialties ; 12.Legally perilous charting practices. IV.Computerized documentation: 13.Computerized patient records ; 14.The future of automated documentation.