(10 reviews) Author: Springhouse ISBN : 9781582555386 New from $18.95 Format: PDFCharting: 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.
- Series: Incredibly Easy! Series
- Paperback: 416 pages
- Publisher: Lippincott Williams & Wilkins; 1 edition (November 3, 2006)
- Language: English
- ISBN-10: 1582555389
- ISBN-13: 978-1582555386
- Product Dimensions: 0.8 x 4.4 x 6.6 inches
- Shipping Weight: 3.2 ounces (View shipping rates and policies)
Download Charting: An Incredibly Easy! Pocket Guide PDF
In today's checkbox "chart-by exception" healthcare environment, nurses are missing much of the objective details that are critical to legal documentation. As nursing faculty and a self-employed Legal Nurse Consultant, I find that narrative charting is an essential basic that should be introduced in nursing school and regularly used in the nursing profession. If done correctly (not too much and not too little), narrative charting can document the details of safe and effective nursing care that may otherwise leave nurses open to allegations of negligence.By D. Dollmeyer
"Charting: An Incredibly Easy! Pocket Guide" gives all levels of nursing an easy resource for this purpose. The book alphabetically lists the common procedures and situations that require narrative charting and gives examples of objective charting of what is standard and necessary to document in each situation. For nursing students and new graduates, the documentation steps guide them through the standard practices for each procedure or situation, which ensures that they don't miss an essential step!
The straight-forward descriptions and examples can be easily altered to include specific details of the situation, whether it be a procedure such as administering a blood transfusion, an adverse event such as hypotensive episode, or a situation such as the patient asking to see their chart or an Against Medical Advice (AMA) discharge.
This product is very helpful in the clinical setting. My instructor came to me one day and asked to borrow it to show the examples to the other students. It is very easy to read and understand.By T. Ballard
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