Nursing Documentation Made Incredibly Easy

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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.