Home / Nursing / Nursing Documentation Made Incredibly Easy

Nursing Documentation Made Incredibly Easy

Edition: 5
9781496394736
ISBN/ISSN:
9781496394736
Publication Date:
July 23, 2018
2018-07-23
9781496394736
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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 ...
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  • Product 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:
    • 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.
  • Specs
    Edition
    5
    ISBN/ISSN
    9781496394736
    Product Format
    Paperback Book
    Trim Size
    7 x 9
    Pages
    312
    Series
    Incredibly Easy! Series®
    Edition
    5
    Publication Date
    July 23, 2018
    Weight
    1.15
  • LWW
  • Table of contents
    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
  • Editorial Reviews
    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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