Medical Charting Demystified

by Richards, Joan; Keogh, Jim

• ISBN13: 9780071498487
• ISBN10: 0071498486
• Edition: 1st
• Format: Paperback
• Copyright: 2008-08-11
• Publisher: McGraw-Hill Education

Summary

The CLEAR and ACCURATE way to navigate MEDICAL CHARTINGTrying 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.

Author Biography

Joan Richards (Edgewater, NJ) is a Clinical Instructor in the Med/Surg area at the N.Y.U. School of Nursing, where she manages up to 10 students in the clinical area focusing on patient management and medication administration. Before that she was an instructor in the Department of Nursing at Bergen Community College. Joan is a Certified Nurse Educator (CNE). She earned a BSN from West Texas A&M University in Canyon, TX, and an MSN from the University of Missouri.Jim Keogh (Jersey City, NJ) is the author of more than 70 books with many in the Demystified series. He is the co-author of Nurse Management Demystified, Medical Billing and Coding Demystified, Pharmacology Demystified, and Microbiology Demystified. Keogh is a former Columbia University faculty member and is currently a member of the faculty at New York University and Saint Peter's College in Jersey City, New Jersey.

Table of Contents

Charting basics

Legal Aspects of Charting

Charting and the Nursing Process

Care Plans

Charting for Acute Care

Charting for Home Care and Long Term Care

Computerized Charting

Transmitting and Securing Electronic Charts

Storage and Retrieving Electronic Charts

Computerize Charting and Controls

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