Nursing Documentation Made Incredibly Easy! 5e IE

Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. 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 - NEWdiscussion 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.