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Nursing Documentation Made Incredibly Easy by Lww

Nursing Documentation Made Incredibly Easy

by Lww
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Book cover type: Paperback
  • ISBN13: 9781496394736
  • Binding: Paperback
  • Subject: N/A
  • Publisher: LWW
  • Publisher Imprint: LWW
  • Publication Date:
  • Pages: 312
  • Original Price: USD 64.99
  • Language: English
  • Edition: N/A
  • Item Weight: 522 grams
  • BISAC Subject(s): Nursing / Fundamentals & Skills

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.

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