Nursing Documentation Made Incredibly Easy
Edition:
5
ISBN/ISSN:
9781496394736
Publication Date:
July 23, 2018
2018-07-23
9781496394736
Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical ...
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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. -
Edition5ISBN/ISSN9781496394736Product FormatPaperback BookTrim Size7 x 9Pages312SeriesIncredibly Easy! Series®Edition5Publication DateJuly 23, 2018Weight0.95
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1 Understanding documentation
Laura Gartner, RN-BC, MSN
2 The nursing process
Laura Gartner, RN-BC, MSN
3 Care plans
Louise Colwill, RN, MSN
4 Documentation systems
Cheryl L. Brady, RN, MSN
5 Enhancing your documentation
Donna Schultice, RN, MSN, FNP-BC, CEN
6 Avoiding legal pitfalls
Antoinette Pretto-Sparkuhl, RN, MSN
7 Documenting procedures
Antoinette Pretto-Sparkuhl, RN, MSN
8 Documenting special situations
Antoinette Pretto-Sparkuhl, RN, MSN
9 Acute care documentation
Louise Colwill, RN, MSN
10 Home health care documentation
Marilyn D. Sellers, RN-BC, MS, FNP-BC
11 Long-term care documentation
Leigh Ann Trujillo, RN, BSN
Appendices -
Doody’s 5 Star! Review
“This is an excellent, comprehensive, and practical resource for anyone, whether a student, novice, or experienced clinical practice nurse, who wants to improve their documentation skills. Every aspect of documentation is effectively covered in this attractive, colorful, and engaging book! Very worthwhile!”
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Nursing Documentation Made Incredibly Easy
ISBN/ISSN: 9781496394736
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