Explaining WTH Happened: Guide to Documentation on a Med/Surg Ward, Including Examples

by Lena Empyema

On an inpatient medical-surgical ward, train wrecks happen. Short staffing happens. CRAZY happens. Make sure documentation happens. Lena Empyema returns to help nurses streamline the tedious aspects of their long, hectic shifts. Deciding what to document and how to summarize pertinent information can require a lot of brain power that nurses may run low on towards the end of 12 or 13 hour shifts. This handy guidebook offers summarized, easy-to-read tips for documentation and extensive examples of standard documentation, receiving report on new patients from the emergency department, PACU, and clinics, what information is necessary during patient transfers and transports, and much more! Why work harder... let Lena guide you through appropriate documentation while you multitask everything else on your plate.

33 pages, Kindle Edition

Published February 15, 2019