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E-grāmata: Medical Charting Demystified

  • Formāts: 350 pages
  • Sērija : Demystified
  • Izdošanas datums: 31-Jul-2008
  • Izdevniecība: McGraw-Hill Professional
  • Valoda: eng
  • ISBN-13: 9780071643504
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  • Formāts: 350 pages
  • Sērija : Demystified
  • Izdošanas datums: 31-Jul-2008
  • Izdevniecība: McGraw-Hill Professional
  • Valoda: eng
  • ISBN-13: 9780071643504
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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 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

Simple enough for a beginner, but challenging enough for an advanced student, Medical Charting Demystified is your key to mastering this vital nursing skill.
Acknowledgment xv
Charting Basics
1(14)
A Patient's Record
2(1)
Types of Charts
3(4)
Writing in a Chart
7(2)
What to Write
9(2)
Fixing Errors
11(1)
Summary
11(1)
Quiz
12(3)
The Legal Aspect of Charing
15(16)
A Patient's Record and the Law
16(1)
HIPAA
17(1)
Charting to Limit Legal Liability
18(2)
Elements of Malpractice
20(1)
Writing an Incident Report
21(1)
Other Legal Documents Part of the Patient's Chart
22(4)
Summary
26(1)
Quiz
27(4)
Charting Medication and Normal Routines
31(22)
The MAR
32(5)
The KARDEX
37(1)
Taking Off Orders
38(4)
Avoid Common Errors When Using the MAR and KARDEX
42(1)
Charting Narcotics
43(1)
IV Administration
43(1)
Intake and Output Flow Chart
44(3)
Transferring a Patient
47(3)
Summary
50(1)
Quiz
50(3)
Patient Care Plans
53(18)
Purpose of a Care Plan
54(3)
Categories of Nursing Diagnosis
57(1)
Care Plan Formats
58(9)
Summary
67(1)
Quiz
68(3)
Acute Care Charting
71(14)
Writing in the Chart
72(10)
Summary
82(1)
Quiz
82(3)
Computer Charting
85(14)
Parts of the Computer Charting System
86(2)
Workstation: An Inside Look
88(2)
Network: An Inside Look
90(2)
Demystifying Wifi Transmission
92(1)
Database: An Inside Look
92(3)
A Tour of the IT Department
95(1)
Summary
96(1)
Quiz
97(2)
Charting Software
99(12)
Why Is There Different Charting Software?
100(1)
Jumping In
101(7)
Summary
108(1)
Quiz
109(2)
To-Do List, Vital Signs, and I&O Charting
111(10)
To-Do List
112(1)
Vital Signs
113(2)
Charting I&O
115(1)
Reviewing Your Entry
116(1)
Summary
117(1)
Quiz
118(3)
Entering Patient Assessment in Charting Software
121(8)
Charting an Assessment
122(3)
Summary
125(1)
Quiz
126(3)
Entering Medication Administration Charting Software
129(12)
Enforcing the Five Rights of Medication Administration
130(2)
The Workflow
132(1)
Using Charting Software to Document Medication Administration
133(3)
Recovering When Things Go Wrong
136(1)
Summary
136(1)
Quiz
137(4)
Entering Orders in Charting Software
141(12)
An Order
141(1)
Entering the Order
142(6)
Compound Order
148(1)
Summary
149(1)
Quiz
149(4)
Final Exam 153(18)
Answers to Quizzes 171(6)
Answers to Final Exam 177(6)
Index 183
Jim Keogh is on the faculty of Columbia University teaching courses in its technology certification program. He has spent 15 years developing computer systems for major Wall Street firms such as Salomen, Inc. and Bear Stearns and has written several best-selling books for Prentice Hall and IDG.