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In its Fourth Edition, Charting Made Incredibly Easy! provides up-to-the-minute guidelines on documentation in a comprehensive, clear, concise, practical, and entertaining manner. The book reviews the fundamental aspects of charting such as the medical record, the nursing process, and legal and professional requirements, guidelines for developing a solid plan of care, and the variety of charting formats currently being used. It also addresses the specific requirements for charting, whether the setting is acute care, home care, or long-term care and rehabilitation. Special elements found throughout the book make it easy to remember key points. This edition includes new information on cultural needs assessment, HIPAA, National Patient Safety Goals, and electronic health records.
In its Third Edition, Charting Made Incredibly Easy! provides up-to-the-minute guidelines on documentation in a comprehensive, clear, concise, practical, and entertaining manner. This edition includes new chapters on computerized documentation and unique professional situations such as contraband, equipment tampering, hostile or sexual advances, media requests for information, and requests to videotape or photograph a patient. Throughout the text, JCAHO requirements are given special emphasis for easy identification, and "Case in Point" sidebars explain the nursing implications of actual court cases. This edition's expanded Practice Makes Perfect section includes alternate-format NCLEX(R)-style questions.
|2||The nursing process||19|
|6||Enhancing your charting||105|
|7||Avoiding legal pitfalls||127|
|9||Charting special situations||195|
|11||Home health care||243|
|JCAHO nursing care and documentation standards||329|
|NANDA taxonomy II codes||333|