Nursing Documentation Made Incredibly Easy

<DIV><B>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</B>. 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.<BR/><BR/><B>Let the experts walk you through up-to-date best practices for nursing documentation, with:</B><ul><li><B><I>NEW</I> and updated</B> , fully illustrated content in quick-read, bulleted format</li><li><B><I>NEW</I></B> discussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliation</li><li><B>Easy-to-retain guidance</B> on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices</li><li><B>Easy-to-read, easy-to-remember content that provides helpful charting examples</B> demonstrating what to document in different patient situations, while addressing the different styles of charting</li><li><B>Outlines the Do's and Don’ts of charting</B> – a common sense approach that addresses a wide range of topics, includin <ul><li>Documentation and the nursing process—assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation</li><li>Documenting the patient’s health history and physical examination</li><li>The Joint Commission standards for assessment</li><li>Patient rights and safety</li><li>Care plan guidelines</li><li>Enhancing documentation</li><li>Avoiding legal problems</li><li>Documenting procedures</li><li>Documentation practices in a variety of settings—acute care, home healthcare, and long-term care</li><li>Documenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behavior</li></ul></li><li><B>Special features include:</B><ul><li><B><I>Just the facts</I></B> – a quick summary of each chapter’s content</li><li><B><I>Advice from the experts</I></B> – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans</li><li><B><I>“Nurse Joy” and “Jake”</I></B> – expert insights on the nursing process and problem-solving</li><li><B><I>That’s a wrap!</I></B> – a review of the topics covered in that chapter</li></ul></li></ul><BR/><B>About the Clinical Editor</B><BR/><BR/> Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.</DIV>