The Essentials of Clinical Documentation: Preparing Students for Clinical Success

FriesenPress
Free sample

This clinical manual is an ideal and standardized platform for preparing nursing students with the essential tools for documenting their nursing process. It teaches nursing students how to gather important data about each client in the clinical setting.

Using this manual, the student nurse will be able to perform high quality documentation that is accurate and consistent in the client profile and laboratory and diagnostics, and their correlation and significance to the client’s diagnosis or diagnoses. This manual also covers the medication administration record, nursing interventions and rationales, and intake and output forms. The Situation Background Assessment Recommendation (SBAR) form and the use of a concept map complete the list of resources provided.
Using this standardized documentation, the student will be able to:
• Identify the primary patient data (past and present), diagnosis, and treatment plan.
• Analyze patient data correlating and drawing conclusions relevant to patient outcome.
• Document finding in a systematic manner.
• Interpret diagnostic findings as relate to patient diagnosis
This manual is intended for use in medical, surgical, and critical care clinical nursing courses.
Read more
Collapse

About the author

Dr. Maxine Jeffery has been a nurse for over twenty years, in critical care nursing. She is an assistant professor and holds the CCRN certification. She obtained Bachelor and Master of Science degrees in nursing from Florida Atlantic University, and a Doctorate in Nursing Practice from the University of Miami, FL. She has held positions as a staff nurse, nursing supervisor, course coordinator for medical-surgical nursing I & II and a lecturer in assessment, medical-surgical, and critical care nursing.

She has chaired, co-chaired and presented at several clinical faculty academies and was responsible for educating and training over two hundred clinical nursing faculty using a standardized curriculum which prepared them for the role of clinical instructor.

She designed undergraduate nursing clinical evaluation tool and clinical documentation for undergraduate nursing program. She is a current and active member of the Sigma Theta Tau International Honors Society (SIGMA) and the American Association of Critical Care Nurses (AACN).
Read more
Collapse
Loading…

Additional Information

Publisher
FriesenPress
Read more
Collapse
Published on
Nov 3, 2020
Read more
Collapse
Pages
192
Read more
Collapse
ISBN
9781525544040
Read more
Collapse
Read more
Collapse
Read more
Collapse
Language
English
Read more
Collapse
Genres
Medical / Nursing / Assessment & Diagnosis
Medical / Nursing / Fundamentals & Skills
Medical / Nursing / General
Read more
Collapse
Content protection
This content is DRM protected.
Read more
Collapse
Read aloud
Available on Android devices
Read more
Collapse
Eligible for Family Library

Reading information

Smartphones and Tablets

Install the Google Play Books app for Android and iPad/iPhone. It syncs automatically with your account and allows you to read online or offline wherever you are.

Laptops and Computers

You can read books purchased on Google Play using your computer's web browser.

eReaders and other devices

To read on e-ink devices like the Sony eReader or Barnes & Noble Nook, you'll need to download a file and transfer it to your device. Please follow the detailed Help center instructions to transfer the files to supported eReaders.
©2021 GoogleSite Terms of ServicePrivacyDevelopersAbout Google|Location: United StatesLanguage: English (United States)
By purchasing this item, you are transacting with Google Payments and agreeing to the Google Payments Terms of Service and Privacy Notice.