Nursing Documentation Made Incredibly Easy

von Lww

312 Seiten, Taschenbuch

Kurzbeschreibung des Verlags

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 chapterAbout the Clinical Editor Kate Stout, RN, MSN, is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport, North Carolina.

• Reihe: LWW
• ISBN: 9781496394736
• Sprache: Englisch
• Erscheinungsdatum: 23.07.2018
• Größe: 229 x 153 mm
• Verlag: Wolters Kluwer Health