Nursing Documentation Made Incredibly Easy

• 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

The New copy of this book will include any supplemental materials advertised. Please check the title of the book to determine if it should include any access cards, study guides, lab manuals, CDs, etc.

The Used, Rental and eBook copies of this book are not guaranteed to include any supplemental materials. Typically, only the book itself is included. This is true even if the title states it includes any access cards, study guides, lab manuals, CDs, etc.