Feeling unsure about the ins and outs of charting? Grasp the essential basics; with the irreplaceable Nursing Documentation Made Incredibly Easy!®; 5th Edition. Packed with colorful images and clear-as-day guidance; this friendly reference guides you through meeting documentation requirements; working with electronic medical records systems; complying with legal requirements; following care planning guidelines; and more. Whether you are a nursing student or a new or experienced nurse; this on-the-spot study and clinical guide is your ticket to ensuring your charting is timely; accurate; and watertight.  Let the experts walk you through up-to-date best practices for nursing documentation; with:  •NEW and updated; fully illustrated content in quick-read; bulleted format•NEWdiscussion of the necessary documentation process outside of charting—informed consent; advanced directives; medication reconciliation•Easy-to-retain guidance on using the electronic medical records / electronic health records (EMR/EHR) documentation systems; and required charting and documentation practices•Easy-to-read; easy-to-remember content that provides helpful charting examples demonstrating what to document in different patient situations; while addressing the different styles of charting•Outlines the Do’s and Don’ts of charting – a common sense approach that addresses a wide range of topics; including: •Documentation and the nursing process—assessment; nursing diagnosis; planning care/outcomes; implementation; evaluation•Documenting the patient’s health history and physical examination•The Joint Commission standards for assessment•Patient rights and safety•Care plan guidelines•Enhancing documentation•Avoiding legal problems•Documenting procedures•Documentation practices in a variety of settings—acute care; home healthcare; and long-term care•Documenting special situations—release of patient information after death; nonreleasable information; searching for contraband; documenting inappropriate behavior•Special features include:•Just the facts – a quick summary of each chapter’s content•Advice from the experts – seasoned input on vital charting skills; such as interviewing the patient; writing outcome standards; creating top-notch care plans•Nurse Joy and Jake – expert insights on the nursing process and problem-solving•That’s a wrap! – a review of the topics covered in that chapter About the Clinical Editor   Kate Stout; RN; MSN; is a Post Anesthesia Care Staff Nurse at Dosher Memorial Hospital in Southport; North Carolina.

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