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Nursing Documentation Made Incredibly Easy (Incredibly Easy! Series¢ç) Fifth Edition
ÆǸŰ¡°Ý  : 49,000¿ø
Àû¸³±Ý  : 1,470Á¡
ÃâÆǻ砠: Wolters Kluwer
ÀúÀÚ  : LWW
¹ßÇàÀÏ  : 2019
ÆÇÇü  : 6.9 x 0.5 x 8.9 inches
ÆäÀÌÁö ¼ö  : 312¸é
ISBN  : 9781496394736
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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.

 

 

Table of contents

1 Understanding documentation
Laura Gartner, RN-BC, MSN
2 The nursing process
Laura Gartner, RN-BC, MSN
3 Care plans
Louise Colwill, RN, MSN
4 Documentation systems
Cheryl L. Brady, RN, MSN
5 Enhancing your documentation
Donna Schultice, RN, MSN, FNP-BC, CEN
6 Avoiding legal pitfalls
Antoinette Pretto-Sparkuhl, RN, MSN
7 Documenting procedures
Antoinette Pretto-Sparkuhl, RN, MSN
8 Documenting special situations
Antoinette Pretto-Sparkuhl, RN, MSN
9 Acute care documentation
Louise Colwill, RN, MSN
10 Home health care documentation
Marilyn D. Sellers, RN-BC, MS, FNP-BC
11 Long-term care documentation
Leigh Ann Trujillo, RN, BSN
Appendices

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