DocuNotes : Clinical Pocket Guide to Effective Charting
Cherie Rebar RN, MSN, MBA, FNP
ISBN-13: 978-0-8036-2092-6
© 2009 Spiral Bound 208 pages
A DAVIS’S NOTES BOOK!
The perfect pocket guide to charting! The popular Davis’s Notes format makes sure that you always have the information you need close at hand to ensure your documentation is not only complete and thorough, but also meets the highest ethical and legal standards.
You’ll even find coverage of the nuances that are relevant to various specialties, including pediatric, OB/GYN, psychiatric, and outpatient nursing. And, the very first Tab reviews the terminology essential to communicate effectively in writing with doctors, other health care professionals, and staff.
It also delivers all of the features that Davis’s Notes users rely on...concise, well-organized, easy-to-reference content in an easy-to-use spiral binding with waterproof, reusable pages.
What students are saying:
“This is really a great resource. Has lots of information in a condensed form and breaks out what is important. Must have for all nursing students.”
– Sabrina Johnson,
“Could not have gotten through class without it.”
– Amanda Leitch,
“This series is awesome to use during your clinical experience. The DocuNotes is very helpful in assisting you with becoming familiar with documenting and charting progress notes, DAR style notes and so on. Highly Recommend for anyone entering an RN program.”
– Danielle DeNisco
DocuNotes
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.