Nursing documentation made incredibly easy! / clinical editor, Kate Stout, RN, MSN, Post Anesthesia Care Staff Nurse, Grand Strand Memorial Hospital, Myrtle Beach, South Carolina.

Format:

Book

Contributor:

Stout, Kate, 1957- editor.

Language:

English

Subjects (All):

Nursing Records.

Documentation.

Nursing records.

Medical Subjects:

Nursing Records.

Documentation.

Physical Description:

1 online resource (ix, 290 pages) : illustrations

Edition:

Fifth edition.

Place of Publication:

Philadelphia : Wolters Kluwer, [2018]

Summary:

Feeling unsure about the ins and outs of charting? Grasp the essential basics, with the irreplaceable Nursing Documentation Made Incredibly Easy !® , 5th Editio n.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 NEW discussion 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, evaluationDocumenting the patient's health history and physical examinationThe Joint Commission standards for assessmentPatient rights and safetyCare plan guidelinesEnhancing documentationAvoiding legal problemsDocumenting proceduresDocumentation practices in a variety of settings-acute care, home healthcare, and long-term careDocumenting special situations-release of patient information after death, nonreleasable information, searching for contraband, documenting inappropriate behaviorSpecial 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.

Contents:

Intro

Title Page

Copyright

Dedication

Contributors

Previous Contributors

Foreword

1 Understanding documentation

A look at documentation

You reach a wide audience

A short history of documentation

Role of documentation

Communication

A growing team

Evaluation of actions

Legal protection

The evidence speaks for itself

Research and education

A reciprocal relationship

Accreditation and licensure

Quality is key

Getting what they deserve

Track with a tracer

Charting clinical competence

Is that safe?

Quality and consistency

Reimbursement

It's payback time . . . or is it?

Examinations aren't just for patients

Keeping the proper care going

Performance improvement

Up to snuff?

Nurse practice acts

Accountability

Types of medical records

A comprehensive record

Source-oriented narrative method

Missing the complete picture?

Get on the same page

Problem-oriented method

Focusing on each problem

Other medical record formats

Designer documentation

Electronic health record

They even have good bedside manners

Suggested references

2 The nursing process

A look at the nursing process

Going through the steps

Assessment

Getting the whole picture

First impressions

Health history

Getting started

Making the most of your time

Physical examination

It's in the details

The Joint Commission standards

Family matters

Is the patient well-equipped?

No yes-or-no answers, please

Learning obstacles

Prioritize, prioritize, prioritize

Nursing diagnosis

Diagnosing a diagnosis

One patient, two types of treatment

Emergencies get top billing

Planning care/outcomes

Take three giant steps

Outcome identification

Keeping it real

Four-part format

Writing outcome statements.

Implementation

Divine intervention

Writing interventions

Documenting interventions

Tailor your style (and format) to policy

Evaluation

Charting changes

A tough transition

The value of evaluation

Whenever within sight

Evaluating expected outcomes

Not resolved? Revise . . .

Documenting evaluation

Get specific

3 Care plans

A look at the nursing care plan

Now a part of the permanent record

A word about words

Style of care plans

Traditional care plans

Looking toward an outcome

Personal, visual, clear

Time isn't on its side

Standardized care plans

Insist on individuality

Computers make combos less cumbersome

These advantages come standard

Is it individualized?

Interdisciplinary contributions to the care plans

Patient-teaching plan

Pointers for the perfect plan

Parts of the teaching plan

Which evaluation techniques are most valuable?

Start simple

Taking different paths to learning

Tracking down teaching tools

Break down language barriers

Documenting the patient-teaching plan

Give it time . . . and thought

Forms, forms, and more forms

Just your type

Care pathways

Practical when predictable

Accomplished a goal? Check it off!

A collaborative effort

Determining the path

A bundle of benefits

Here's where it gets complicated . . .

Choosing the right path

Priorities in the pathway

4 Documentation systems

A look at documentation systems

To write or not to write?

Narrative documentation

Using narrative documentation

Documentation mania!

Observe and take note

One thought leads to another

A narrative with a happy story

The narrative takes a turn for the worse . . .

Problem-oriented medical record

A multidiscipline approach.

Four-part format

A four-star knowledge

Dividing the diagnoses

It's as easy as 1, 2, 3, 4, 5 . . .

Plan on patient participation

A clean SOAP or SOAPIE component

POMR pros . . .

. . . and cons

PIE system

Using the PIE system

Pieces of PIE

Got a problem with that?

Keeping track

Reevaluate and review

Reasons to give PIE a try

Problems with PIE

FOCUS (F-DAR) system

Coming into FOCUS (F-DAR)

Writing FOCUS (F-DAR) progress notes

Lights, camera, data, action, response!

DAR-e to succeed?

FOCUS (F-DAR) downers

Charting by exception

CBE guidelines

Document deviations

Defining normal parameters

Get your guidelines here

CBE format

Making progress?

Fill in the blanks

Checks, asterisks, and arrows

Note normalcy

Make more marks

Care-ful combinations

More checks and asterisks

It's exception-all

CBE shortcomings

Information station

Multitasker

The upside

The downside

Using an EHR

Mum's the word

Starting the record

Individual access

Practitioner's use

Help for managing meds

Ready, set, document

Fast and functional

Follow protocol

Types of EHR systems

Talk, touch, or click

Adding your personal touch

What's your type?

Nursing information system

From passive to interactive

Nursing minimum data set

Consistent and coded

Nurse's little helper

But it's always about the patient

Nursing outcomes classification system

Voice-activated systems

Look ma, no hands!

Report support and more

Hanging on every word

Additional system features

Patient schedules

Bar code technology

Medication administration

To be discontinued . . .

Sorry, wrong number

Streamlined service

Blood administration

Support provided

When computers fail.

Choosing a documentation system

Getting better and better

Does your documentation measure up?

Are you committed? Serve on a committee . . .

5 Enhancing your documentation

A look at expert documentation

Documenting completely, concisely, and accurately

Say what?

Don't be wishy-washy

Maintaining objectivity

Don't put words in other people's mouths

Secondhand data

Ensuring timeliness

Document ASAP

Give them the time of day

Put your documentation in order

Better late than never

Ensuring legibility

No pencils, please

Spelling counts

Using abbreviations appropriately

Correcting errors properly

Signing documents

To be continued . . .

What you didn't see can hurt you

Practitioner's orders

Written or electronic orders

Heading off mistakes

Preprinted orders

Verbal orders

From words to paper

Telephone orders

From phone to paper

Questioning practitioner's orders

Chart authority

Stop, question, and document

6 Avoiding legal pitfalls

A look at legal pitfalls in documentation

The aim is communication

Legal standards

In a confused state? Read on . . .

Accreditation organizations/federal regulations

The more things change, the more they stay the same

Every relationship brings with it responsibility

The ties that bind

Documenting defensively

How to chart

Rule #1: Stick to the facts

Rule #2: Avoid labeling

Rule #3: Be specific

Rule #4: Use neutral language

Rule #5: Eliminate bias

Rule #6: Keep the record intact

Rule #7: Know your EHR

What to document

Rule #1: Document significant situations or unusual events

Rule #2: Document complete assessment data

Rule #3: Document discharge instructions

When to document

Don't get ahead of yourself.

Who should document

Finish what you started

Risk management and documentation

Mining the records for potential risk

Preventing adverse events

Reporting the out of the ordinary

Let's review

Making sure everyone is on the same page

Managing incidents

The claim chain reaction

Eight legal hazards

Hazard #1: Incident reports

The form's function

It's an eyewitness report

Hazard #2: Informed consent

Waive it good-bye

Hazard #3: Advance directives

A change may be in order

Who else can give a DNR order?

A patient's right

State-ments

Hazard #4: Patients who refuse treatment

The patient who says "no"

Get to them early

Hazard #5: Documenting for unlicensed personnel

Countersign-language

Hazard #6: Using restraints

The laws, they are a-changing . . .

Putting restraints on abusing restraints

The earlier, the better

One day at a time-no more

Getting into training

Hazard #7: Patients who request to see their charts

Don't just hand it over

Hazard #8: Patients who leave AMA

Taking aim at the AMA form

Relate the patient's state

The case of the missing patient

7 Documenting procedures

Guidelines for documenting procedures

You document MARvelously

No room for exceptions

Paging the practitioner . . .

Double team

I.V. therapy

Basic documentation

Getting complicated

Don't forget the family

We interrupt this service . . .

Accounting for autotransfusions

Reacting to a suspected transfusion reaction

Surgical incision care

Records that get around

Who's up first?

Detailed care and discharge data

Pacemaker care

Peritoneal dialysis

Peritoneal lavage

Chest tube

The documentation goes on and on

Cardiac monitoring

Keep on chartin'.

Chest physiotherapy.

Notes:

Preceded by Charting made incredibly easy. 4th ed. c2010.

Includes bibliographical references and index.

ISBN:

9781496394743

1496394747