Authors: Lippincott Williams & Wilkins
ISBN-13: 9781605471969, ISBN-10: 1605471968
Format: Paperback
Publisher: Lippincott Williams & Wilkins
Date Published: May 2009
Edition: 4th Edition
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 in acute care, home care, and long-term care and rehabilitation settings. 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.
1 | Understanding charting | 3 |
2 | The nursing process | 19 |
3 | Care plans | 39 |
4 | Charting systems | 57 |
5 | Computerized charting | 91 |
6 | Enhancing your charting | 105 |
7 | Avoiding legal pitfalls | 127 |
8 | Charting procedures | 163 |
9 | Charting special situations | 195 |
10 | Acute care | 211 |
11 | Home health care | 243 |
12 | Long-term care | 281 |
JCAHO nursing care and documentation standards | 329 | |
NANDA taxonomy II codes | 333 |