Chart To Save Your Rn License

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• Author : Lena Empyema
• Publisher : Independently Published
• File Size : 30,6 Mb
• Release Date : 2021-08-11
• Total pages : 176
• ISBN : 9798548570581
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Download Chart to Save Your RN License in PDF, Epub, and Kindle

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.

• Author : Lena Empyema
• Publisher : Unknown
• File Size : 48,5 Mb
• Release Date : 2020-01-06
• Total pages : 99
• ISBN : 165656548X
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Download Nursing Narrative Note Examples to Save Your License in PDF, Epub, and Kindle

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!

• Author : Anonim
• Publisher : Lippincott Williams & Wilkins
• File Size : 19,9 Mb
• Release Date : 2009
• Total pages : 424
• ISBN : 0781791944
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Download Nursing Know-how in PDF, Epub, and Kindle

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.

• Author : Anonim
• Publisher : Lippincott Williams & Wilkins
• File Size : 30,9 Mb
• Release Date : 2011
• Total pages : 516
• ISBN : CHI:089489207
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Download Chart Smart in PDF, Epub, and Kindle

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

• Author : Cherie Rebar
• Publisher : F.A. Davis
• File Size : 42,9 Mb
• Release Date : 2009-04-10
• Total pages : 175
• ISBN : 9780803623361
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Download DocuNotes in PDF, Epub, and Kindle

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.

• Author : Kathy Quan
• Publisher : Simon and Schuster
• File Size : 17,7 Mb
• Release Date : 2009-01-17
• Total pages : 208
• ISBN : 9781440520457
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Download 150 Tips and Tricks for New Nurses in PDF, Epub, and Kindle

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!

• Author : Karen Stuart Gelety
• Publisher : Unknown
• File Size : 55,6 Mb
• Release Date : 2010-11-01
• Total pages : 50
• ISBN : 0975999869
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Download Nursing Notes the Easy Way in PDF, Epub, and Kindle

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.

• Author : Merlande Jean,Youseline Baptiste
• Publisher : Unknown
• File Size : 46,8 Mb
• Release Date : 2020-04-04
• Total pages : 64
• ISBN : 9798633941418
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Download Chart Like A Pro in PDF, Epub, and Kindle

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!

• Author : Lorie A. Brown
• Publisher : Unknown
• File Size : 12,6 Mb
• Release Date : 2014-01-20
• Total pages : 117
• ISBN : 163173931X
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Download Law and Order for Nurses in PDF, Epub, and Kindle

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.

• Author : Beth Hawkes
• Publisher : Simon and Schuster
• File Size : 55,7 Mb
• Release Date : 2020-05-26
• Total pages : 192
• ISBN : 9781510755147
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Download First-Year Nurse in PDF, Epub, and Kindle

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!

• Author : Debra Sullivan
• Publisher : F.A. Davis
• File Size : 54,6 Mb
• Release Date : 2011-12-22
• Total pages : 288
• ISBN : 9780803629974
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Download Guide to Clinical Documentation in PDF, Epub, and Kindle

Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

• Author : Mosby
• Publisher : Mosby
• File Size : 24,6 Mb
• Release Date : 2006
• Total pages : 0
• ISBN : 0323034349
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Download Mosby's Surefire Documentation in PDF, Epub, and Kindle

Offering clear, practical guidelines for how, what, and when to document for more than 100 of the most common and most important situations nurses face, this essential resource details exactly what information to consider and document, to ensure quality patient care, continuity of care, and legal protection for the nurse and the institution where the nurse works.

• Author : Institute of Medicine,Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine
• Publisher : National Academies Press
• File Size : 47,5 Mb
• Release Date : 2011-02-08
• Total pages : 700
• ISBN : 9780309208956
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Download The Future of Nursing in PDF, Epub, and Kindle

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.

• Author : Brenda Walter Holloway
• Publisher : F.A. Davis
• File Size : 47,5 Mb
• Release Date : 2013-08-27
• Total pages : 195
• ISBN : 9780803640443
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Download Physical Assessment Check-Off Notes in PDF, Epub, and Kindle

Reduce your anxieties and build the knowledge base and experience you need to pass the check-off exam. Based upon actual “check-off” forms that faculty commonly use for grading, this unique guide gives you instant access to the information necessary for conducting and documenting a routine adult well-patient physical assessment. Full-color illustrations detail every assessment technique.

• Author : Kate Stout
• Publisher : Lippincott Williams & Wilkins
• File Size : 17,9 Mb
• Release Date : 2018-06-05
• Total pages : 312
• ISBN : 9781496394743
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Download Nursing Documentation Made Incredibly Easy in PDF, Epub, and Kindle

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.