Nursing Documentation Made Incredibly Easy [Paperback]

Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceableNursing 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:

• NEWand 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 guidanceon 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 examplesdemonstrating 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
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