The CLEAR and ACCURATE way to navigate MEDICAL CHARTING
Trying to chart a course through the complex task of keeping patient records? Here's your lifeline! Medical Charting Demystified gives you the tools you need to prepare and update both computerized and written charts.
You'll learn about chart components, what to write in a chart, and how to correct errors. Medical Charting Demystified covers entering vital signs, assessments, test results, medications, procedures, patient care plans, and more. Details on the legal aspects of medical charting, including confidentiality, HIPAA, malpractice, and informed consent, are also included. Hundreds of examples and illustrations make it easy to understand the material, and end-of-chapter quizzes and a final exam help reinforce learning.
This fast and easy guide offers:
- Coverage of the five common charting systems--narrative, problem-oriented, problem-intervention-evaluation, FOCUS, and charting by exception
- Details on the MAR and the KARDEX
- An overview of computer charting software
- A time-saving approach to performing better on an exam or at work
Simple enough for a beginner, but challenging enough for an advanced student, Medical Charting Demystified is your key to mastering this vital nursing skill.
ABOUT THE AUTHORS
Joan Richards, RN, MSN, CNE, is a clinical instructor at New York University College of Nursing, and a joint practice clinician at Englewood (N.J.) Hospital and Medical Center.
Jim Keogh, RN, is a member of the faculty at both New York University and Saint Peter's College in New Jersey. He is a graduate nurse and is the coauthor of Medical-Surgical Nursing Demystified, Pharmacology Demystified, Medical Billing and Coding Demystified, Nurse Management Demystified, and several other books.
TABLE OF CONTENTS
Chapter 1: Charting Basics
Chapter 2: The Legal Aspect of Charting
Chapter 3: Charting Medication and Normal Routines
Chapter 4: Patient Care Plans
Chapter 5: Acute Care Charting
Chapter 6: Computer Charting
Chapter 7: Charting Software
Chapter 8: To-Do List, Vital Signs, and I&O Charting
Chapter 9: Entering Patient Assessment in Charting Software
Chapter 10: Entering Medication Administration Charting Software
Chapter 11. Entering Orders to Charting Software
Answers to Quizzes
Answers to Final Exam