Nursing Documentation Made Incredibly Easy!

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. 1 Understanding documentation Laura Gartner, RN-BC, MSN 1 2 The nursing process Laura Gartner, RN-BC, MSN 13 3 Care plans Louise Colwill, RN, MSN 37 4 Documentation systems Cheryl L. Brady, RN, MSN 59 5 Enhancing your documentation Donna Schultice, RN, MSN, FN P-BC, CEN 99 6 Avoiding legal pitfalls Antoinette Pretto-Sparkuhl, RN, MSN 120 7 Documenting procedures Antoinette Pretto-Sparkuhl, RN, MSN 155 8 Documenting special situations Antoinette Pretto-Sparkuhl, RN, MSN 193 9 Acute care documentation Louise Colwill, RN, MSN 208 10 Home health care documentation Marilyn D. Sellers, RN-BC, MS, FNP-BC 236 11 Long-term care documentation Leigh Ann Trujillo, RN, BSN 258 Appendices 281 Glossary 282 Index 285