The Essentials of Clinical Documentation: Preparing Students for Clinical Success

· FriesenPress

About this ebook

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.

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).

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