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.
Contributors and consultants
Not another boring foreword
Part I: Charting in contemporary health care
Part II: Charting procedures and special situations
Part III: Charting in health care settings
Appendices
Practice makes perfect
Joint Commission nursing care and documentation standards
NANDA International nursing diagnoses
Glossary
Selected references
Index