Synopsis

In its Fourth Edition, Charting Made Incredibly Easy! provides up-to-the-minute guidelines on documentation in a comprehensive, clear, concise, practical, and entertaining manner. The book reviews the fundamental aspects of charting such as the medical record, the nursing process, and legal and professional requirements, guidelines for developing a solid plan of care, and the variety of charting formats currently being used. It also addresses the specific requirements for charting, whether the setting is acute care, home care, or long-term care and rehabilitation. Special elements found throughout the book make it easy to remember key points. This edition includes new information on cultural needs assessment, HIPAA, National Patient Safety Goals, and electronic health records.