Feeling unsure about the ins and outs of charting? Grasp the essential
basics, with the irreplaceable Nursing Documentation Made Incredibly
Easy !(R), 5th Editio n.
Packed with colorful images and clear-as-day guidance, this friendly
reference guides you through meeting documentation requirements, working
with electronic medical records systems, complying with legal
requirements, following care planning guidelines, and more. Whether you
are a nursing student or a new or experienced nurse, this on-the-spot
study and clinical guide is your ticket to ensuring your charting is
timely, accurate, and watertight.
Let the experts walk you through up-to-date best practices for nursing
documentation, with:
NEW and updated, fully illustrated content in quick-read, bulleted
format
NEW discussion of the necessary documentation process outside of
charting--informed consent, advanced directives, medication
reconciliation
Easy-to-retain guidance on using the electronic medical records /
electronic health records (EMR/EHR) documentation systems, and required
charting and documentation practices
Easy-to-read, easy-to-remember content that provides helpful charting
examples demonstrating what to document in different patient
situations, while addressing the different styles of charting
Outlines the Do's and Don'ts of charting - a common sense approach
that addresses a wide range of topics, including:
Documentation and the nursing process--assessment, nursing diagnosis,
planning care/outcomes, implementation, evaluation
Documenting the patient's health history and physical examination
The Joint Commission standards for assessment
Patient rights and safety
Care plan guidelines
Enhancing documentation
Avoiding legal problems
Documenting procedures
Documentation practices in a variety of settings--acute care, home
healthcare, and long-term care
Documenting special situations--release of patient information after
death, nonreleasable information, searching for contraband, documenting
inappropriate behavior
Special features include:
-
Just the facts - a quick summary of each chapter's content
-
Advice from the experts - seasoned input on vital charting
skills, such as interviewing the patient, writing outcome standards,
creating top-notch care plans
-
"Nurse Joy" and "Jake" - expert insights on the nursing process
and problem-solving
-
That's a wrap! - a review of the topics covered in that chapter
About the Clinical Editor
Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher
Memorial Hospital in Southport, North Carolina.
