Now nurses can chart the Incredibly Easy! way with this remarkable reference. They'll find easy-to-follow directions for charting thoroughly and accurately in all clinical situations. And they'll learn to improve speed and efficiency, reduce legal risks, and meet requirements for licensing, accreditation, and reimbursement. Contents include charting basics: understanding charting, the nursing process, plans of care, and charting systems; charting in contemporary health care: acute care, home health care, longterm care, and rehabilitation; and special topics: enhancing charting, avoiding legal pitfalls, and documenting procedures.
Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy!®, 5th Edition. 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 NEWdiscussion 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.
Part of the Springhouse Incredibly Easy! Series(TM), this Second Edition provides current information about charting in a comprehensible, clear, fun and concise manner. Three sections cover Charting Basics, Charting in Contemporary Health Care, and Special Topics. New features include expanded coverage of computerized documentation and charting specific patient care procedures, plus current JCAHO standards both in the text and appendix, chapter summaries, and a new section with case study questions and answers. Amusing graphics and cartoon characters call special attention to important information. Entertaining logos throughout the text alert the reader to critical information, Thought Pillows identify key features of documentation forms, and the glossary defines difficult or often-misunderstood terms.
Pediatric Nursing Made Incredibly Easy! Second Edition Whether you are prepping for the NCLEX or certification exam, looking for an aid to class materials, or just want to refresh your skills, Pediatric Nursing Made Incredibly Easy!is the answer. Part of the award-winning Made Incredibly Easy! Series, this fun, practical guide addresses pediatric care and childhood disorders in light of each level of child development, with a family-involved care approach. Full of expert insight and MIE’s trademark wit, this lively reference addresses the full range of common pediatric conditions, and illuminates the many roles of the pediatric nurse. Features: · Current data on more than 100 pediatric disorders, including genetic and cognitive disorders · Coverage of topics including: cultural considerations, hospital care, children with disabililties and terminal illness, pain assessment and management, drug metabolism, healthcare team collaboration, ethics and professional boundaries · Full color inserts illuminate complex concepts · “Nurse Joy” and other illustrated characters offer tips and insights · Easy-reference format with concise, bulleted content · Numerous tables, illustrations and flow charts · Special features: · Just the Facts – quick summary at start of each chapter · Quick Quiz – at end of each chapter · Advice from Experts – experienced practitioners’ insights · It’s all relative – teaching tips and checklists for family education · Growing pains – developmental stage descriptions, expectations and risks · Cultured pearls – insights on unique aspects of care by cultural group · Glossary of essential pediatric terms, selected references, and online sources
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.
NCLEX-RN QUESTIONS & ANSWERS MADE INCREDIBLY EASY!, 7E is designed to help pre-licensure nursing students prepare for the licensing examination. This book and its accompanying electronic resources feature thousands of questions at the application level or above to prompt active learning and higher-order thinking. The book’s seven parts cover the basics of NCLEX test construction and how students should prepare, the four major content areas of pre-licensure programs (medical-surgical, psychiatric/mental health, maternity, and pediatrics), a section on issues in nursing, and three comprehensive tests of varying lengths that help simulate the actual NCLEX experience. The questions align with the National Council of State Boards of Nursing (NCSBN) 2016 RN test plan. Throughout the book, the Made Incredibly Easy design, art, and captions help to engage students and present a fun, relaxed, encouraging, and supportive learning experience. Other features include the use of all the types of alternate-format questions and detailed rationale for both correct and incorrect answers.
Charting: An Incredibly Easy! Pocket Guide provides time-starved nurses with essential documentation guidelines in a streamlined, bulleted format, with illustrations, logos, and other Incredibly Easy! features. The book is conveniently pocket sized for quick reference anytime and anywhere. The first section reviews the basics of charting, including types of records, dos and dont's, and current HIPAA and JCAHO regulations. The second section, alphabetically organized, presents hundreds of examples and guidelines for accurately charting everyday occurrences. Logos include Help Desk best practices tips; Form Fitting completed forms that exemplify top-notch documentation; Making a Case documentation-related court cases; and Memory Jogger mnemonics.
The CLEAR and ACCURATE way to navigate MEDICAL CHARTING Trying to chart a course through the complex task of keeping patient records? Here's your lifeline! Medical Charting Demystified gives you the tools you need to prepare and update both computerized and written charts. You'll learn about chart components, what to write in a chart, and how to correct errors. Medical Charting Demystified covers entering vital signs, assessments, test results, medications, procedures, patient care plans, and more. Details on the legal aspects of medical charting, including confidentiality, HIPAA, malpractice, and informed consent, are also included. Hundreds of examples and illustrations make it easy to understand the material, and end-of-chapter quizzes and a final exam help reinforce learning. This fast and easy guide offers: Coverage of the five common charting systems--narrative, problem-oriented, problem-intervention-evaluation, FOCUS, and charting by exception Details on the MAR and the KARDEX An overview of computer charting software A time-saving approach to performing better on an exam or at work Simple enough for a beginner, but challenging enough for an advanced student, Medical Charting Demystified is your key to mastering this vital nursing skill.
Reviews the terminology for written communications with physicians and staff. Describe the types of documentation, including SOAP notes and DART charts. Details the documentation of history taking, including medical, social, and family history, physical assessments, and systems. Covers the documentation of nursing skills and procedures as well as medication administration. Addresses the documentation required in specialized fields such as OB/GYN, pediatrics, psychiatric, and outpatient nursing. Includes how-tos for template, electronic, and other forms of charting.
Worried about handling the challenges of emergency nursing? Skillfully handle the daily demands of the emergency room, with the fully updated Emergency Nursing Made Incredibly Easy!®, 3rd Edition. Full of colorful illustrations, humor and friendly expert advice, this go-to reference offers solid, step-by-step guidance on the assessments, exams, tests and treatments involved in emergency, trauma and critical care — all in the enjoyable Incredibly Easy® style.
