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Charting Made Incredibly Easy!

Publication Date
September 12, 2014
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  • Description

    In its Fourth Edition, Charting Made Incredibly Easy! provides up-to-the-minute guidelines on documentation in a comprehensive, clear, concise, practical, and entertaining manner. The book reviews the fundamental aspects of charting such as the medical record, the nursing process, and legal and professional requirements, guidelines for developing a solid plan of care, and the variety of charting formats currently being used. It also addresses the specific requirements for charting, whether the setting is acute care, home care, or long-term care and rehabilitation. Special elements found throughout the book make it easy to remember key points. This edition includes new information on cultural needs assessment, HIPAA, National Patient Safety Goals, and electronic health records.

  • Specs
    Product Format
    Incredibly Easy! Series®
    Publication Date
    September 12, 2014
  • About The Author(s)
    Lippincott Williams & Wilkins
  • Features
    --New! Cultural needs assessment (pp 26-28)
    --New! National Patient Safety Goals (p.8)
    --New! Up-to-date information on electronic health records
    --Joint Commission documentation standards highlighted throughout the text
    --'Practice makes Perfect' - Case study questions and answers at the end of the book to assess knowledge of documentation
    --Each chapter features:
    --A summary of key points
    --Clear, simple explanations of all difficult concepts
    --Definitions of key terms
    --Easy-to-remember memory joggers
    --Bullets, ballot boxes, and checklists that make it easy to spot important points at a glance
    --Charts, illustrations, and tables that highlight key facts
    --Fully completed chart forms
    --Quick quizzes - at the end of each chapter that help the reader assess learning
    --Entertaining logos that alert the reader to critical information. These include:
    --'Art of the chart' - completed examples of forms with key points clearly highlighted
    --'Advice from the experts' - pointers, tips, and guidelines for precise, patient-focused, litigation-proof charting
    --'Case in point' - documentationrelated court cases and their nursing implications
    --'That's a wrap!' - end-of-chapter summaries
    --Incorporation of Joint Commission documentation requirements
    --Joy and all her friends add familiarity and fun to important charting concepts
  • Table of contents

    Contributors and consultants

    Not another boring foreword

      Part I: Charting in contemporary health care

    • Chapter 1: Understanding charting
    • Chapter 2: The nursing process
    • Chapter 3: Care plans
    • Chapter 4: Charting systems
    • Chapter 5: Computerized charting
    • Chapter 6: Enhancing your charting
    • Chapter 7: Avoiding legal pitfalls
    • Part II: Charting procedures and special situations

    • Chapter 8: Charting procedures
    • Chapter 9: Charting special situations
    • Part III: Charting in health care settings

    • Chapter 10: Acute care
    • Chapter 11: Home health care
    • Chapter 12: Long- term care


    Practice makes perfect

    Joint Commission nursing care and documentation standards

    NANDA International nursing diagnoses


    Selected references


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  • Questions and Answers
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