Charting Made Incredibly Easy

Now nurses can chart the Incredibly Easy! way with this remarkable reference. They'll find easy-to-follow directions for charting thoroughly and accurately in all clinical situations. And they'll learn to improve speed and efficiency, reduce legal risks, and meet requirements for licensing, accreditation, and reimbursement. Contents include charting basics: understanding charting, the nursing process, plans of care, and charting systems; charting in contemporary health care: acute care, home health care, longterm care, and rehabilitation; and special topics: enhancing charting, avoiding legal pitfalls, and documenting procedures.

Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. 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.

Part of the Springhouse Incredibly Easy! Series(TM), this Second Edition provides current information about charting in a comprehensible, clear, fun and concise manner. Three sections cover Charting Basics, Charting in Contemporary Health Care, and Special Topics. New features include expanded coverage of computerized documentation and charting specific patient care procedures, plus current JCAHO standards both in the text and appendix, chapter summaries, and a new section with case study questions and answers. Amusing graphics and cartoon characters call special attention to important information. Entertaining logos throughout the text alert the reader to critical information, Thought Pillows identify key features of documentation forms, and the glossary defines difficult or often-misunderstood terms.

Provides information on documentation issues, including electronic medical records, legal and ethical implications, and documentation in acute cases, along with a variety of charting examples.

Reviews the terminology for written communications with physicians and staff. Describe the types of documentation, including SOAP notes and DART charts. Details the documentation of history taking, including medical, social, and family history, physical assessments, and systems. Covers the documentation of nursing skills and procedures as well as medication administration. Addresses the documentation required in specialized fields such as OB/GYN, pediatrics, psychiatric, and outpatient nursing. Includes how-tos for template, electronic, and other forms of charting.

Ever wonder what to put in a nursing note? This pocket sized guide provides you with over a hundred templates for written and verbal comminication in nursing to help you.

Reduce your anxieties and build the knowledge base and experience you need to pass the check-off exam. Based upon actual “check-off” forms that faculty commonly use for grading, this unique guide gives you instant access to the information necessary for conducting and documenting a routine adult well-patient physical assessment. Full-color illustrations detail every assessment technique.

Wound Care Made Incredibly Easy! Second Edition covers fundamental wound care principles and procedures, using a light-hearted, entertaining style. Coverage begins with skin anatomy and physiology, wound progression and healing, and factors that can delay or complicate healing. Subsequent chapters cover wound assessment and monitoring and wound care planning, procedures, and products. The book includes eight pages of full-color illustrations, intervention algorithms for diabetic, arterial, and venous ulcers, and eye-catching logos that emphasize key points. This new edition includes coverage of malignant wounds and palliative care. A new logo highlights considerations for special populations, including pediatric, geriatric, and bariatric patients.