Nursing Documentation Made Incredibly Easy (Incredibly Easy! Series®)

Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy !u00ae , 5th Editio n.
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 Donu2019ts 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, evaluationDocumenting the patientu2019s health history and physical examinationThe Joint Commission standards for assessmentPatient rights and safetyCare plan guidelinesEnhancing documentationAvoiding legal problemsDocumenting proceduresDocumentation practices in a variety of settings—acute care, home healthcare, and long-term careDocumenting special situations—release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behaviorSpecial features include: Just the facts – a quick summary of each chapteru2019s content Advice from the experts – seasoned input on vital charting skills, such as interviewing the patient, writing outcome standards, creating top-notch care plans u201cNurse Joyu201d and u201cJakeu201d – expert insights on the nursing process and problem-solving Thatu2019s 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.