Medical Charting Demystified: A Self- teaching Guide

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
• 作者簡介

  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.

• 目次

  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
  Final Exam
  Answers to Quizzes
  Answers to Final Exam
  Index