This thoroughly revised and updated edition of Nursing Documentation Made Incredibly Easy provides the fundamental aspects of charting, and other essential documentation skills, nurses need to master in order to effectively relay information on the patient's care, past history, etc., ensure continuity of care across the healthcare team and provide a legal record of all patient interactions.
The book includes coverage of medical records, the nursing process, legal and professional requirements, guidelines for developing solid care plans, informed consent, advanced directives, and medication reconciliation, charting formats and documentation in EMR/EHR systems. 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.
