Description
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:
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NEW and updated , fully illustrated content in quick-read, bulleted format
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NEW discussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation
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Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices
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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
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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
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Special features include:
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Just the facts – a quick summary of each chapter’s content
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Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans
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“Nurse Joy” and “Jake” – expert insights on the nursing process and problem-solving
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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.
