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Nursing Documentation Made Incredibly Easy : Incredibly Easy! Series(r) - Stout

Nursing Documentation Made Incredibly Easy

Incredibly Easy! Series(r)

By: Stout

Paperback Published: 10th August 2018
ISBN: 9781496394736
Number Of Pages: 312

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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, 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.

  • ISBN: 9781496394736
    ISBN-10: 1496394739
    Series: Incredibly Easy! Series(r)
    Audience: Professional
    Format: Paperback
    Language: English
    Number Of Pages: 312
    Published: 10th August 2018
    Country of Publication: US
    Dimensions (cm): 22.61 x 17.53  x 1.27
    Weight (kg): 0.52
    Edition Number: 5

    Earn 149 Qantas Points
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