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 formatNEW discussion of the necessary documentation process outside of charting—informed consent, advanced directives, medication reconciliationEasy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practicesEasy-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 chartingOutlines 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, evaluationDocumenting the patient’s health history and physical examinationThe Joint Commission standards for assessmentPatient rights and safetyCare plan guidelinesEnhancing documentationAvoiding legal problemsDocumenting proceduresDocumentation practices in a variety of settings—acute care, home healthcare, and long-term careDocumenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behaviorSpecial features include:Just the facts – a quick summary of each chapter’s contentAdvice 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-solvingThat’s a wrap! – a review of the topics covered in that chapterAbout the Clinical EditorKate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.
