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:
About the Clinical Editor
Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.
Book Information
ISBN 9781496394736
Author LWW
Format Paperback
Page Count 312
Imprint Lippincott Williams and Wilkins
Publisher Lippincott Williams and Wilkins
Weight(grams) 431g
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.
Book Information
ISBN 9781496394736
Author LWW
Format Paperback
Page Count 312
Imprint Lippincott Williams and Wilkins
Publisher Lippincott Williams and Wilkins
Weight(grams) 431g
