Hello,
Does anyone have any recommendations on books that are helpful in knowing the whats,whens,and hows of documentation? I am a nursing student who struggles with documentation every week in the clinical setting. I always seem to omit relevant information. There are several books out there, but was just wondering if anyone had any favorites. Thanks!
Don't have any names of books, but as an english student I get the Nursing times Journal, look up their website on google (or any other search engine) and look for articles on documentation, also ask other nurses and students in the clinical area, everyone has the same problems untill they get the knowledge. your nursing tutors should also give you numerous boaring hand outs about documentation that we all stuff away in the corner of the room untill that day when you first go to the clinical area and realise "ARGH I KNOW NOTHING ABOUT DOCUMENTATION" a word of advice in the mean time, If you don't write it down you havn't done it.
Chill jcmoo, we've all been there.
After trianing for 1 year I still am,
Good luck
I have just completed my first yr at uni - did Legal Issues + concepts in nursing, we covered quite a bit on documentation/pt records.
Some legal books for health professionals have whole chapters on documentation + various issues which can arise with certain practices in documentation, pt records.
B/c I am from Australia the legal text books I used wont be of much help. However, you may want to check out Potter & Perry's Fundamentals of Nursing which has quite a bit on documentation.
I'm in Canada and if you go to the CNO website they have a nursing compendium of standards under the publications section (I think) and it has a whole section on documentation.
