Medical Charting Demystified - Paperback
by Joan Richards (Author), Jim Keogh (Author)
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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 exceptionDetails on the MAR and the KARDEXAn overview of computer charting softwareA time-saving approach to performing better on an exam or at work
Author Biography
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.
Details
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