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Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy ! (R) , 5th Editio n. 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. n n Let the experts walk you through up-to-date best practices for nursing documentation, with: n n NEW and updated , fully illustrated content in quick-read, bulleted format n NEW discussion of the necessary documentation process outside of charting-informed consent, advanced directives, medication reconciliation n Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems, and required charting and documentation practices n 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 n Outlines the Dos and Donts of charting - a common sense approach that addresses a wide range of topics, including: n n Documentation and the nursing process-assessment, nursing diagnosis, planning care/outcomes, implementation, evaluation n Documenting the patients health history and physical examination n The Joint Commission standards for assessment n Patient rights and safety n Care plan guidelines n Enhancing documentation n Avoiding legal problems n Documenting procedures n Documentation practices in a variety of settings-acute care, home healthcare, and long-term care n Documenting special situations-release of patient information after death, nonreleasable information, searching for contraband, documenting
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Vânzător: Libris.ro
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