Lippincott Williams & WilkinsRead More
In its Fourth Edition, Charting Made Incredibly Easy! provides up-to-the-minute guidelines on documentation in a comprehensive, clear, concise, practical, and entertaining manner. The book reviews the fundamental aspects of charting such as the medical record, the nursing process, and legal and professional requirements, guidelines for developing a solid plan of care, and the variety of charting formats currently being used. It also addresses the specific requirements for charting in acute care, home care, and long-term care and rehabilitation settings. Special elements found throughout the book make it easy to remember key points. This edition includes new information on cultural needs assessment, HIPAA, National Patient Safety Goals, and electronic health records.
Charting: An Incredibly Easy! Pocket Guide provides time-starved nurses with essential documentation guidelines in a streamlined, bulleted format, with illustrations, logos, and other Incredibly Easy! features. The book is conveniently pocket sized for quick reference anytime and anywhere.
The first section reviews the basics of charting, including types of records, dos and dont's, and current HIPAA and JCAHO regulations. The second section, alphabetically organized, presents hundreds of examples and guidelines for accurately charting everyday occurrences. Logos include Help Desk best practices tips; Form Fitting completed forms that exemplify top-notch documentation; Making a Case documentation-related court cases; and Memory Jogger mnemonics.
Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management.
Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.