基本説明
The previous ed.: 2005.
Full Description
Publisher's Noteguaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. 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.
Contents
Contributors and consultantsNot another boring forewordPart I: Charting in contemporary health careChapter 1: Understanding chartingChapter 2: The nursing processChapter 3: Care plansChapter 4: Charting systemsChapter 5: Computerized chartingChapter 6: Enhancing your chartingChapter 7: Avoiding legal pitfallsPart II: Charting procedures and special situationsChapter 8: Charting proceduresChapter 9: Charting special situationsPart III: Charting in health care settingsChapter 10: Acute careChapter 11: Home health careChapter 12: Long-term careAppendicesPractice makes perfectJoint Commission nursing care and documentation standardsNANDA International nursing diagnosesGlossarySelected referencesIndex
