"Documentation can be both overwhelming and absolutely critical. This concise text bridges the gap. This quick-reference handbook provides guiding principles as well as many practical examples of correct documentation. It is a must-have volume for the student and professional nurse in a clinical setting."--BOOK JACKET.

Nursing Process --Historical Perspective -- The Nursing Process and Critical Thinking -- The Nursing Process and Problem Solving -- The Nursing Process and Decision Making -- The Nursing Process and Holistic Care -- Assessment -- Purpose of Assessment -- Database -- Collecting Data -- Types of Assessment -- Comprehensive Assessment -- Focused Assessment -- Ongoing Assessment -- Sources of Data -- Types of Data -- Validating the Data -- Organizing the Data -- Hierarchy of Needs -- Body Systems Model -- Functional Health Patterns -- Theory of Self-Care -- Interpreting the Data -- Documenting the Data -- Diagnosis -- Components of a Nursing Diagnosis -- Two-Part Statement -- Three-Part Statement -- Writing the Nursing Diagnosis Statement -- Types of Nursing Diagnoses -- Collaborative Problems -- Planning and Outcome Identification -- Prioritizing the Nursing Diagnoses -- Goals -- Expected Outcomes -- Developing Specific Nursing Interventions -- Categories of Nursing Interventions -- Recording the Nursing Care Plan -- Implementation -- Requirements for Effective Implementation -- Types of Nursing Interventions -- Documenting and Reporting Interventions -- Evaluation -- Evaluation -- Nursing Audit -- Documentation -- Documentation As Communication -- Purposes of Health Care Documentation -- Communication -- Education -- Research -- Legal and Practice Standards -- Informed Consent -- Advance Directives -- State Nursing Practice Acts -- Joint Commission on Accreditation of Healthcare Organizations -- Reimbursement.