Download or read book Chart to Save Your RN License written by Lena Empyema and published by Independently Published. This book was released on 2021-08-11 with total page 176 pages. Available in PDF, EPUB and Kindle. Book excerpt: You can be an excellent nurse in the clinical setting and still fail to prove that you are an excellent nurse if your documentation is inadequate. Having worked in a variety of inpatient and outpatient settings, I understand the obstacles nurses face. There's just not time, nor do nurses have the mental energy to meticulously document every little thing on top of the rest of their to-do list. That's part of why I became passionate about documentation education. It doesn't have to be an overwhelming, endless challenge to chart exhaustively in hopes that you enter enough data into the chart to defend yourself one day. Rather, leveraging the most critical data, knowing how to format notes and exactly what to say, and when to spend five minutes dumping information into the chart can be learned skills that make documentation faster, easier, and less stressful, while doing a better job of defending your actions. The Importance of Documentation & Overcoming Obstacles Purpose(s) of Documentation Defensive Charting Obstacles Impacting Quality of Medical Record Overcoming Obstacles Legal Responsibilities of the Nurse Duties of the Nurse Nurse Practice Acts Duties of the Hospital Hospital Policy vs. State Board of Nursing Regulations Reasonable Prudence Failure to Fulfill (Document) Responsibilities Fulfilling Responsibilities vs. Documenting Responsibilities What if Responsibilities Aren't Fulfilled? Mistakes Happen Professional Liability Insurance Malpractice Medical Negligence Acting with Malice Fraud What Happens When a Nurse is Charged with Malpractice? What to Do if You Receive Notification of a Claim Common Charting Mistakes & How to Avoid Them The Most Common Errors Charting By Exception & Charting to Capture Minimal Data "But I've Always Charted This Way, and Nothing Bad Has Happened Yet..." What You Should Be Charting How and What to Chart Quick Glance Charting Checklists What is a Timely Manner? Documenting Assessments Sample Focused Assessment Criteria Sharing the Responsibility Modifying Electronic Data Abbreviations Standing Orders Early Warning Systems Scores & Scales Informed Consent Special Circumstances Paper Charting Writing an Incident Report Patient Leaving AMA Patient Threatening to Sue You Identifying Patient Belongings Another Member of the Team is Not Documenting Correctly Restraints Defective Equipment Suspected Abuse Patient Requesting to View Their EMR on Hospital Computer Narrative Notes When & How to Write Notes One Note or Several Notes? Daily Narrative Notes Examples of Common Notes Written As-Needed How to Title Narrative Notes How to Format Notes Using Patient Names in Notes Length of Notes Create a Template Tips for Less Stress When Charting BONUS: How I Chart on a "Typical" Shift ABOUT THE AUTHOR: I'm Andrea, RN-MSN. Perfecting my own documentation and working to find concrete guidelines to share with my fellow nurses has become my passion. As I gained more knowledge and researched the dusty, forgotten corners of the internet for obscure evidence-based practice and case studies, becoming a subject matter expert on nursing documentation lit a spark because sharing this information helps empower nurses to understand exactly what should appear in their patient charts, where, when it should entered, and how it should be phrased.
Download or read book Nursing Know how written by and published by Lippincott Williams & Wilkins. This book was released on 2009 with total page 424 pages. Available in PDF, EPUB and Kindle. Book excerpt: Provides information on documentation issues, including electronic medical records, legal and ethical implications, and documentation in acute cases, along with a variety of charting examples.
Download or read book Chart Smart written by and published by Springhouse Corporation. This book was released on 2011 with total page 516 pages. Available in PDF, EPUB and Kindle. Book excerpt: Chart Smart: the A-to-Z Guide to Better Nursing Documentation tells nurses exactly what to document in virtually every type of situation they may encounter on the job, no matter where they practice--hospital, medical office, outpatient, rehabilitation facility, long-term care facility, or home. This portable handbook has nearly 300 entries that cover documentation required for common diseases, major emergencies, complex procedures, and difficult situations involving patients, families, other health care team members, and supervisors. In addition to patient care, this book also covers documenta
Download or read book DocuNotes written by Cherie Rebar and published by F.A. Davis. This book was released on 2009-04-10 with total page 203 pages. Available in PDF, EPUB and Kindle. Book excerpt: The perfect guide to charting! The popular Davis’s Notes format makes sure that you always have the information you need close at hand to ensure your documentation is not only complete and thorough, but also meets the highest ethical and legal standards. You’ll even find coverage of the nuances that are relevant to various specialties, including pediatric, OB/GYN, psychiatric, and outpatient nursing.
Download or read book Nursing Narrative Note Examples to Save Your License written by Lena Empyema and published by . This book was released on 2020-01-06 with total page 99 pages. Available in PDF, EPUB and Kindle. Book excerpt: Nursing can be nuts. On a twelve-hour shift, the last thing most nurses want to do is sit down and draft a lengthy note describing the craziness that occurred. Written by a nurse, for nurses, this book is chock full of narrative note examples describing hypothetical situations to help you describe the, well, the indescribable. Some shifts are just like that!
Download or read book 150 Tips and Tricks for New Nurses written by Kathy Quan and published by Simon and Schuster. This book was released on 2009-01-17 with total page 208 pages. Available in PDF, EPUB and Kindle. Book excerpt: With long hours, huge responsibilities, and average pay, nursing is often as challenging as it is rewarding. By teaching new nurses what to expect, how to get what they want, and how to succeed in today's medical environment, this book is the one-dose treatment to prevent burnout. Written in an easy-to-read, direct, and honest way, this helpful handbook will teach new nurses what they didn't learn in nursing school. Veteran R.N. Kathy Quan offers readers information on how to: balance a hectic new schedule (for work, sleep, and life) deal with doctors avoid illness themselves continue education while working cope with death of patients (the first time, and after) and more With this book, nurses get real-life advice on how to cope, perform, and excel in their field--one shift at a time!
Download or read book Nursing Notes the Easy Way written by Karen Stuart Gelety and published by . This book was released on 2010-11-01 with total page 50 pages. Available in PDF, EPUB and Kindle. Book excerpt: Ever wonder what to put in a nursing note? This pocket sized guide provides you with over a hundred templates for written and verbal comminication in nursing to help you.
Download or read book Chart Like A Pro written by Merlande Jean and published by . This book was released on 2020-04-04 with total page 64 pages. Available in PDF, EPUB and Kindle. Book excerpt: If as a new nurse, you've been having sleepless nights understanding the whole concept of charting and how to do it like the pros, keep reading....You Are About To Learn How To Master The Craft Of Charting Fast, Accurately And Efficiently, Just Like The Pros And Ultimately Become A Valuable Member Of The Healthcare Provider You Work For!As nurses, we're always thinking about all the ways we can apply our wealth of medical knowledge to care for patients in need. But after we complete our program, pass our exams and ace our first interview, we come across some aspects of beginning our career that we didn't anticipate, and that we probably didn't hear in school. One of those is definitely the process of charting information in our new role. The fact that you're here means that you've heard about it before.Maybe you're already trying to come to grips with it but are finding a hard time doing so, or want to improve how you handle it.If that's the case, then I guess you've been asking yourself: What is the best and most efficient way to chart?What kind of information am I supposed to chart and how?Why does it seem like too much work? Is there a way to do it quickly?How do I get started?Lucky for you, this book has all the answers to these and other related questions. It is designed to help you understand the concept of chatting well, cart off the feeling of intimidation by offering you all the facts and details you require and get you started with the process like a pro to make sure you have the easiest time, and become the efficient, stress-free nurse you've always desired to become.Here is what you'll learn from it: -How to manage and handle time, date, signature and error-What you need to know before you chart-How to use objective and subjective data-How to use abbreviation and medical terminology -How to do assessment charting -How to chart admission and discharge information-How to chart refusals-How to chart about medication -How to chart co-workers' names-How to chart for pain and antibiotics...and so much more!The well-being of your patients highly depends on accurate information recorded and passed across different departments or levels of the health institution, including between physicians and pharmacists.Even if charting seems complex at the moment, this book's easy to follow and practical approach to charting will literally dissolve your fears and concerns and hold you by the hand until you start charting like the pros!If you're ready to learn the basics and get a new perspective of this seemingly demanding task, then all you have to do is grab your own copy of this practical, straightforward guide today and get started!Click Buy Now With 1-Click or Buy Now to get started!
Download or read book Nursing Documentation written by Ellen Thomas Eggland and published by Lippincott Williams & Wilkins. This book was released on 1994 with total page 276 pages. Available in PDF, EPUB and Kindle. Book excerpt: Focuses on the communicatiion skills that are the key to good documentation.
Download or read book Law and Order for Nurses written by Lorie A. Brown and published by . This book was released on 2014-01-20 with total page 117 pages. Available in PDF, EPUB and Kindle. Book excerpt: Law and Order for Nurses: The Easy Way to Protect Your License and Your Livelihood teaches nurses how to protect their most valuable asset, their license. The book uses a system called GIFTS which is an acronym for tools which allow nurses to speak their mind, stand in their power and be a change agent to improve patient care. When nurses use their GIFTS, they are able to protect their license. The book discusses numerous case studies of real life situation of nurses who did not use their GIFTS and found themselves before the state Licensing Boards. It shows which GIFTS the nurse was not using so that other nurses do not make the same mistakes.
Download or read book Nursing Documentation Made Incredibly Easy written by Kate Stout and published by Lippincott Williams & Wilkins. This book was released on 2018-06-05 with total page 487 pages. Available in PDF, EPUB and Kindle. Book excerpt: Publisher's Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product. 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.
Download or read book The Future of the Nursing Workforce in the United States written by Peter Buerhaus and published by Jones & Bartlett Publishers. This book was released on 2009-10-06 with total page 329 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Future of the Nursing Workforce in the United States: Data, Trends and Implications provides a timely, comprehensive, and integrated body of data supported by rich discussion of the forces shaping the nursing workforce in the US. Using plain, jargon free language, the book identifies and describes the key changes in the current nursing workforce and provide insights about what is likely to develop in the future. The Future of the Nursing Workforce offers an in-depth discussion of specific policy options to help employers, educators, and policymakers design and implement actions aimed at strengthening the current and future RN workforce. The only book of its kind, this renowned author team presents extensive data, exhibits and tables on the nurse labor market, how the composition of the workforce is evolving, changes occurring in the work environment where nurses practice their profession, and on the publics opinion of the nursing profession.
Download or read book First Year Nurse written by Beth Hawkes and published by Simon and Schuster. This book was released on 2020-05-26 with total page 192 pages. Available in PDF, EPUB and Kindle. Book excerpt: An Indispensable Guide for First-Time Nurses on Working with Doctors, the Joys of the Night Shift, and Facing Mistakes! You've completed the necessary education, passed the exams, and you're finally ready for your first year as a professional nurse. But there is still trepidation, accompanied by many unanswered questions. A true first year of nursing 101 guide, this book covers topics like managing feedback, working with doctors, working night shift, and recovering from a mistake. Writer and nursing professional Beth Hawkes draws from her own experiences to offer expert tips for first-timers venturing into this important discipline. Writing in a manner that's digestible and including illustrative anecdotes along the way, Hawkes will put readers at ease with her clear advice and directives—many of which can be applied in professional settings outside of nursing. She offers rookie nurses sample questions to help guide them on how they should be communicating with preceptors and colleagues, from morning to night. The perfect gift for nurses just entering the field!
Download or read book Charting written by Lippincott Williams & Wilkins and published by Lippincott Williams & Wilkins. This book was released on 2006-11-01 with total page 420 pages. Available in PDF, EPUB and Kindle. Book excerpt: Charting: An Incredibly Easy! Pocket Guide provides time-starved nurses with essential documentation guidelines in a streamlined, bulleted format, with illustrations, logos, and other Incredibly Easy! features. The book is conveniently pocket sized for quick reference anytime and anywhere. The first section reviews the basics of charting, including types of records, dos and dont's, and current HIPAA and JCAHO regulations. The second section, alphabetically organized, presents hundreds of examples and guidelines for accurately charting everyday occurrences. Logos include Help Desk best practices tips; Form Fitting completed forms that exemplify top-notch documentation; Making a Case documentation-related court cases; and Memory Jogger mnemonics.
Download or read book The Future of Nursing 2020 2030 written by National Academies of Sciences Engineering and Medicine and published by . This book was released on 2021-09-30 with total page pages. Available in PDF, EPUB and Kindle. Book excerpt: The decade ahead will test the nation's nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. Nurses work in a wide array of settings and practice at a range of professional levels. They are often the first and most frequent line of contact with people of all backgrounds and experiences seeking care and they represent the largest of the health care professions. A nation cannot fully thrive until everyone - no matter who they are, where they live, or how much money they make - can live their healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Nurses have a critical role to play in achieving the goal of health equity, but they need robust education, supportive work environments, and autonomy. Accordingly, at the request of the Robert Wood Johnson Foundation, on behalf of the National Academy of Medicine, an ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine conducted a study aimed at envisioning and charting a path forward for the nursing profession to help reduce inequities in people's ability to achieve their full health potential. The ultimate goal is the achievement of health equity in the United States built on strengthened nursing capacity and expertise. By leveraging these attributes, nursing will help to create and contribute comprehensively to equitable public health and health care systems that are designed to work for everyone. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity explores how nurses can work to reduce health disparities and promote equity, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030. This work builds on the foundation set out by The Future of Nursing: Leading Change, Advancing Health (2011) report.
Download or read book The Future of Nursing written by Institute of Medicine and published by National Academies Press. This book was released on 2011-02-08 with total page 700 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Future of Nursing explores how nurses' roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by health care reform and to advance improvements in America's increasingly complex health system. At more than 3 million in number, nurses make up the single largest segment of the health care work force. They also spend the greatest amount of time in delivering patient care as a profession. Nurses therefore have valuable insights and unique abilities to contribute as partners with other health care professionals in improving the quality and safety of care as envisioned in the Affordable Care Act (ACA) enacted this year. Nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care in the United States. To ensure its members are well-prepared, the profession should institute residency training for nurses, increase the percentage of nurses who attain a bachelor's degree to 80 percent by 2020, and double the number who pursue doctorates. Furthermore, regulatory and institutional obstacles-including limits on nurses' scope of practice-should be removed so that the health system can reap the full benefit of nurses' training, skills, and knowledge in patient care. In this book, the Institute of Medicine makes recommendations for an action-oriented blueprint for the future of nursing.
Download or read book Health Professions Education written by Institute of Medicine and published by National Academies Press. This book was released on 2003-07-01 with total page 191 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Institute of Medicine study Crossing the Quality Chasm (2001) recommended that an interdisciplinary summit be held to further reform of health professions education in order to enhance quality and patient safety. Health Professions Education: A Bridge to Quality is the follow up to that summit, held in June 2002, where 150 participants across disciplines and occupations developed ideas about how to integrate a core set of competencies into health professions education. These core competencies include patient-centered care, interdisciplinary teams, evidence-based practice, quality improvement, and informatics. This book recommends a mix of approaches to health education improvement, including those related to oversight processes, the training environment, research, public reporting, and leadership. Educators, administrators, and health professionals can use this book to help achieve an approach to education that better prepares clinicians to meet both the needs of patients and the requirements of a changing health care system.
