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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.
Contributors and consultants Not another boring foreword Part I: Charting in contemporary health care Chapter 1: Understanding charting Chapter 2: The nursing process Chapter 3: Care plans Chapter 4: Charting systems Chapter 5: Computerized charting Chapter 6: Enhancing your charting Chapter 7: Avoiding legal pitfalls Part II: Charting procedures and special situations Chapter 8: Charting procedures Chapter 9: Charting special situations Part III: Charting in health care settings Chapter 10: Acute care Chapter 11: Home health care Chapter 12: Long- term care Appendices Practice makes perfect Joint Commission nursing care and documentation standards NANDA International nursing diagnoses Glossary Selected references Index