Nursing Documentation Made Incredibly Easy / Edition 5

by LWW

Overview

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.

Product Details

ISBN-13:	9781496394736
Publisher:	LWW
Publication date:	07/31/2018
Series:	Incredibly Easy! Series®
Edition description:	Fifth
Pages:	312
Sales rank:	519,915
Product dimensions:	6.90(w) x 8.80(h) x 0.60(d)

Table of Contents

1 Understanding documentation Laura Gartner, RN-BC, MSN 1

2 The nursing process Laura Gartner, RN-BC, MSN 13

3 Care plans Louise Colwill, RN, MSN 37

4 Documentation systems Cheryl L. Brady, RN, MSN 59

5 Enhancing your documentation Donna Schultice, RN, MSN, FN P-BC, CEN 99

6 Avoiding legal pitfalls Antoinette Pretto-Sparkuhl, RN, MSN 120

7 Documenting procedures Antoinette Pretto-Sparkuhl, RN, MSN 155

8 Documenting special situations Antoinette Pretto-Sparkuhl, RN, MSN 193

9 Acute care documentation Louise Colwill, RN, MSN 208

10 Home health care documentation Marilyn D. Sellers, RN-BC, MS, FNP-BC 236

11 Long-term care documentation Leigh Ann Trujillo, RN, BSN 258

Appendices 281

Glossary 282

Index 285

Editorial Reviews

Reviewer: Lisa R. Binns-Emerick, MSN, GNP-BC, FGNLA (Wayne State University Physician Group)
Description: Documentation is essential to safe, quality patient care. This book is an excellent comprehensive tool for students, staff nurses, or practitioners to have at the ready. The fifth edition has been updated to include contemporary, vital topics to assure documentation that is clear, concise, and accurately communicates outcomes of care. This edition incorporates topics that are appropriate for the current healthcare environment. The previous edition was published in 2010.
Purpose: The purpose is to offer a comprehensive review of documentation and its importance to nursing both for providing quality care and for communicating the care given to colleagues and those in other professions. The book emphasizes the importance that nursing plays in documentation that is accurate, timely, and clear. The author meets the objective of providing a thorough yet practical review of documentation.
Audience: The intended audience includes student nurses as well as novice or seasoned nurses in educational and practice settings. The contributors have experience academically as well as clinically, which provides a nice blend of expertise that is evident in the quality of the content.
Features: This book is well organized into 11 chapters. Topics include understanding documentation, the nursing process, care plans, documentation systems, enhancing documentation, avoiding legal pitfalls, documenting procedures, and special situations, as well as acute care, home healthcare and long-term care documentation. The impact of this book lies in the content as well as its practicality, with the information presented in an attractive, colorful fashion with well done tables.
Assessment: This is an excellent, comprehensive, and practical resource for anyone, whether a student, novice or experienced clinical practice nurse, who wants to improve their documentation skills. Every aspect of documentation is effectively covered in this attractive, colorful and engaging book! Very worthwhile!

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