Nursing Documentation Made Incredibly Easy!

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.