Nursing Documentation Made Incredibly Easy!

Publication Year: 2018

Edition: 5th Ed.

Authors/Editor: Stout, Kate

Publisher: Lippincott Williams & Wilkins (LWW)

ISBN: 978-1-49-639473-6

Doody's Star Rating®: Score: 97

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Description

Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition.

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

Details

Platform: Ovid
Publisher: Lippincott Williams & Wilkins (LWW)
Product Type: Book
Author/Editor: Stout, Kate
ISBN: 978-1-49-639473-6
Specialty:
References
Pathophysiology
Medical/Surgical Nursing
Dictionaries & Word References
Language: English
Edition: 5th Ed.
Pages: 312
Year: 2018
Doody's Star Rating®: Score: 97

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