Clinical Documentation Quick Reference Guide for Long-Term Care, Second Edition

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Clinical Documentation Quick Reference Guide for Long-Term Care, Second Edition

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Clinical Documentation Quick Reference Guide for Long-Term Care, Second Edition

Barbara Acello, MS, RN

This handy resource will help nurses improve their efficiency and quality of documentation by guiding them through 150 of the most common conditions, procedures, and situations encountered in a long-term care facility.

Organized by system or subject, with a detailed and comprehensive description of each symptom or condition, nurses will have a thorough list of what to check for and what to document during every shift, based on the specific circumstances of a given resident.

This book identifies necessary information on diseases, how to quickly assess and document by providing thorough checklists of what to look for and document in a resident, no matter the diagnosis.

With the help of Clinical Documentation Quick Reference for Long-Term Care, you can be confident you’re providing your residents with the best quality of care while also maintaining compliant documentation.

SNF Clinical Documentation Quick Reference Guide will:

  • Help nurses save time while achieving accurate, comprehensive documentation for every resident in their care
  • Provide clinicians with documentation procedures for the 150 most common conditions, procedures, and situations encountered in long-term care
  • Aid in identifying problems and related interventions through assessment guidelines by system
  • Updates include tips on assessing and documenting more eye and ear conditions; GERD, opioid-induced constipation, more on cardiovascular diseases, skin disorders, and order readbacks. Each previous condition has also been updated to ensure best practices in documentation.

Published: December 2018

Pages: 264

Table of Contents

Section 1: Assessments
Antibiotics, Guidelines for Nursing Monitoring and Documentation

  • Cincinnati Pre-Hospital Stroke Scale, The Glasgow Coma Scale
  • Guidelines for Neurological Checks for Head Injuries
  • Witnessed and Unwitnessed Falls
  • Neurological Checks
  • Pupil Assessment
  • Radiation Therapy, External

Section 2: Cancer

  • 10 Warning Signs of Cancer
  • Brachytherapy
  • Breast Cancer (Malignant)
  • Chemotherapy
  • Kaposi’s Sarcoma
  • Prostate Cancer
  • Radiation Therapy, External

Section 3: Cardiovascular

  • Anemia
  • Atherosclerosis
  • Atrial Fibrillation
  • Blood Clots
  • Cardiovascular Conditions
  • Chest Pain
  • Congestive Heart Failure, Comprehensive
  • Congestive Heart Failure, Acute
  • Congestive Heart Failure, Chronic
  • Edema
  • Hematologic Conditions, Anticoagulant Therapy
  • Ischemic Heart Disease
  • Myocardial Infarction, Suspected
  • Orthostatic Hypotension
  • Postoperative Care Coronary Artery Bypass Graft Surgery (Heart Bypass Surgery)
  • Postoperative Care Percutaneous Transluminal Coronary Angioplasty,
  • Angioplasty, or Cardiac Stent Placement

Section 4: Change in Condition

  • Guidelines for Assessing and Documenting Acute Conditions
  • Nursing Observation, Assessment, and Documentation for Illness,
  • General Signs and Symptoms (Unknown Etiology)
  • Incident Report

Section 5: Delirium, Dementia, and Alzheimer’s Disease

  • Delirium
  • Dementia, Major Forms of
  • Alzheimer’s Disease

Section 6: Emergencies

  • Code Documentation

Section 7: Endocrine System

  • Endocrine System Conditions
  • Diabetes, Unstable or Potential for Instability
  • Metabolic Disorders, Other Miscellaneous

Section 8: End-of-Life Care

  • Death of Resident
  • Postmortem Care of Persons With Medical Implants

Section 9: Eye, Ear, Nose, and Throat

  • Eye, Ear, Nose, Throat Conditions
  • Cataracts
  • Cochlear Implants
  • Conjunctivitis
  • Glaucoma
  • Macular Degeneration

Section 10: Gastrointestinal

  • Gastrointestinal System Conditions
  • Gastrointestinal Upset, Distress, or Other Related Conditions
  • Cirrhosis of the Liver
  • Constipation, Fecal Impaction
  • Constipation, Opioid-Induced
  • Crohn’s Disease
  • Gastroesophageal Reflux Disease
  • Irritable Bowel Syndrome
  • Peritonitis, Suspected
  • Total Parenteral Nutrition
  • Ulcerative Colitis

Section 11: Genitourinary System

  • Dehydration, Actual or Risk for

Section 12: Implants

  • Implanted Medication Pumps
  • Pacemakers and Defibrillators

Section 13: Infection Control

  • Infection, General Signs and Symptoms (Unknown Etiology)
  • Antibiotics 
  • Clostridium difficile Diarrhea, C. diff, Pseudomembranous Colitis 
  • Carbapenem-Resistant Enterobacteriaceae
  • Hepatitis
  • Herpes Zoster
  • HIV and AIDS
  • Necrotizing Fasciitis
  • Respiratory System Infection
  • Sepsis, Urosepsis
  • Upper Respiratory Infection
  • Urinary Tract Infection and Genitourinary Disorders

Section 14: Integumentary System

  • Integumentary System Conditions
  • Candidiasis
  • Cellulitis
  • Kennedy Terminal Ulcer, The
  • Major Skin Disorders
  • Pressure Injuries, Assessment
  • Pressure Injuries, Staging
  • Psoriasis
  • Skin Check
  • Skin Tears
  • Tissue Tolerance and Pressure Injuries

Section 15: Medication

  • Warfarin (Coumadin) Anticoagulant Drug Therapy

Section 16: Mental and Psychosocial

  • Behavior Change
  • Mental and Consciousness Evaluation, Resident
  • Psychotic Disorders

Section 17: Monitoring

  • Initial Documentation Guidelines for All Conditions for Which Monitoring Is Required
  • Mandatory Documenting and Reporting
  • Resident Monitoring

Section 18: Musculoskeletal

  • Amputation
  • Arthritis
  • Arthritis, Degenerative Joint Disease, Joint Degeneration of Leg, Knee, Hands, and Arms
  • Arthritis, Degenerative Joint Disease, Joint Degeneration of Spine (Back)
  • Compartment Syndrome
  • Falls
  • Fractures
  • Hip Fracture, Acute Injury
  • Hip Fracture, Postoperative: Repair or Replacement
  • Hip Precautions
  • Musculoskeletal Conditions, Fractures
  • Total Knee Arthroplasty

Section 19: Neurological

  • Neurological Conditions
  • Amyotrophic Lateral Sclerosis
  • Autonomic Dysreflexia
  • Cerebrovascular Accident
  • Head Injury/Potential Subdural Hematoma
  • Head Injury, Suspected Head Injury, or Unwitnessed Fall
  • Multiple Sclerosis
  • Post Polio Syndrome
  • Seizure Activity
  • Transient Ischemic Attack

Section 20: Pain

  • Pain Assessment
  • Pain, Documenting Nursing Management
  • Pain Resources

Section 21: Parasites

  • Bedbugs (Cimex lectularius)
  • Fire Ants
  • Fleas
  • Head Lice
  • Scabies

Section 22: Respiratory

  • Respiratory System Conditions
  • Aspiration Precautions
  • Chronic Obstructive Pulmonary Disease
  • Hypoxemia
  • Influenza
  • Pneumonia, Bacterial Lung Infections
  • Pulse Oximetry Values, Pulse Oximeter Monitoring Documentation, Pulse Oximeter Action
  • Tracheostomy, Resident With a

Section 23: Restorative

  • Restorative Nursing Documentation
  • Restorative Nursing, Documentation Clarity and Consistency
  • Restorative Nursing, Observations and Relevant Documentation of ADLs

Section 24: Special Documentation Issues

  • Special Documentation Issues
  • Telephone Orders
  • What Not to Document

Section 25: Transitions

  • Admission Assessment, Complete Physical Assessment
  • Discharge

About the Author

Barbara Acello, MS, RN, is an independent nurse consultant and educator in Denton, Texas. She is a member of the Texas Nurses™ Association, NANDA International, and the American College of Healthcare Administrators, where she was honored with the Educator of the Year Award for 2007 and the Journalism Award for 2009. Acello has worked as a director of nursing, administrator, and long-term care facility consultant and educator; she has held numerous corporate-level positions in eight states. Presently, she is involved with freelance consulting, lecturing, and writing. She has written many textbooks, journal articles, and other materials related to acute and long-term care nursing, as well as nursing assistant practice and education. Although she has worked in acute care, emergency room, and EMS, long-term care is her preferred practice setting. She is committed to improving working conditions, education, and professionalism for nurses and nursing assistants in long-term care facilities.