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