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:
Simple enough for a beginner, but challenging enough for an advanced student, Medical Charting Demystified is your key to mastering this vital nursing skill.
Chapter 1: Charting basics
Chapter 2: Legal Aspects of Charting
Chapter 3: Charting and the Nursing Process
Chapter 4: Care Plans
Chapter 5: Charting for Acute Care
Chapter 6: Charting for Home Care and Long Term Care
Chapter 7: Computerized Charting
Chapter 8: Transmitting and Securing Electronic Charts
Chapter 9: Storage and Retrieving Electronic Charts
Chapter 10: Computerize Charting and Controls