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
Publisher: Lippincott Williams & Wilkins (LWW)
Product Type: Book
Author/Editor: Stout, Kate
Dictionaries & Word References
Edition: 5th Ed.
Doody's Star Rating®:
Nursing Documentation Made Incredibly Easy!