Nursing Documentation Made Incredibly Easy

Nursing Documentation Made Incredibly Easy Description

Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy !® , 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, evaluationDocumenting the patient&s health history and physical examinationThe Joint Commission standards for assessmentPatient rights and safetyCare plan guidelinesEnhancing documentationAvoiding legal problemsDocumenting proceduresDocumentation practices in a variety of settings´ care, home healthcare, and long-term careDocumenting special situations&release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behaviorSpecial 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.