MEDICAL DOCUMENTATION IN NURSING PRACTICE

Discover the key aspects of maintaining medical records in the daily practice of nurses and midwives. This publication is an invaluable source of knowledge to help you understand and apply the rules for maintaining records in medical facilities. Ensure confidence and professionalism in every step of your work.

• Complete discussion of the rules for maintaining medical records
• Detailed information on obtaining consent for treatment
• Practical templates for documents to use in everyday work
• Explanation of aspects of storing and sharing documentation
• Discussion of the rules for controlling medical records
• Tips for obtaining statements from the patient and his legal representative

Medical documentation is not only a formality, but above all a tool to support the diagnostic and therapeutic process. Properly maintained documentation ensures patient safety, protects the rights of medical personnel and provides a basis for settlements with the National Health Fund. This book is a practical guide to help you avoid errors and ambiguities in medical records.

The authors, Maciej Gibiński and Renata Ciemierz, are experienced specialists in the field of medical law and nursing. Their knowledge and experience guarantee that you will find reliable and up-to-date information in this publication. The book was published by the renowned PZWL publishing house, which further confirms its high quality and substantive value.

Regardless of your work experience, this book will be a valuable support in your daily practice. You will find answers to questions regarding the maintenance of medical records, obtaining consent for treatment, storing and sharing records, and the rules for controlling them. Thanks to the attached document templates, you will be able to immediately apply the acquired knowledge in practice.

Take care of your knowledge and professionalism. Reach for this publication and gain confidence in maintaining medical records. Your work will become more effective and you will be able to focus on what is most important - caring for the patient.

The book contains 202 pages, format 234x165 mm, paperback. Published in 2014 by PZWL.