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Author Debbie Ohl, RN, M, Msc., PhD, has developed more than 100 proven, person-centered care plans that you can modify to fit the individual needs of your residents. You ll be able to satisfy requirements of the assessment process while care planning more efficiently."
The new edition of Nursing Care Planning Made Incredibly Easy is the resource every student needs to master the art of care planning, including concept mapping. Starting with a review of the nursing process, this comprehensive resource provides the foundations needed to write practical, effective care plans for patients. It takes a step-by-step approach to the care planning process and builds the critical thinking skills needed to individualize care in the clinical setting. Special tips and information sections included throughout the book help students incorporate evidence-based standards and rationales into their nursing interventions.
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.
Over 150 care plans designed as "template pages" ready to photocopy, individualize with preferences and needs, and place directly into resident charts.
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 in acute care, home care, and long-term care and rehabilitation settings. 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.
Looking to develop a more comprehensive plan of care while improving MDS 3.0 accuracy? MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care helps you navigate recent changes to the RAI and includes more than 100 customizable care plan templates. With many updated regulations already in effect, this timely book covers the IMPACT Act, QAPI, person-centered care, and survey changes, as well as the changes resulting from the ICD- 10 transition. Each care plan provides a framework for guiding the review of trigger areas and clarifying a resident's functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. These thorough assessments provide the interdisciplinary team additional information to help them develop a comprehensive plan of care. By modifying the care plans provided in this resource, you'll fit the individual needs of your residents while satisfying the requirements of the new assessment process. This product will help facilities: - Save time developing person-centered care plans using more than 100 customizable templates - Evaluate and create valuable Care Area Assessments (CAA) and improve MDS 3.0 accuracy - Help customers navigate recent changes to the RAI - Integrate the voice of the resident, family, and staff in the development of the care plan - Be confident they're making use of proven tools and expert guidance
Part of the Springhouse Incredibly Easy! Series(TM), this Second Edition provides current information about charting in a comprehensible, clear, fun and concise manner. Three sections cover Charting Basics, Charting in Contemporary Health Care, and Special Topics. New features include expanded coverage of computerized documentation and charting specific patient care procedures, plus current JCAHO standards both in the text and appendix, chapter summaries, and a new section with case study questions and answers. Amusing graphics and cartoon characters call special attention to important information. Entertaining logos throughout the text alert the reader to critical information, Thought Pillows identify key features of documentation forms, and the glossary defines difficult or often-misunderstood terms.
2024 Edition for MDS v1.19.1. 39 Psychosocial Care Plans, 11 monitoring and tracking forms, 7 CAAs, Cognitive, Mood, Behavior, Medications, Discharge Planning. Current with all RAI Manual Updates, PDPM, Trauma Informed Care, Surveyor Guidelines, and Federal Regulatory Changes. Psychosocial Outcome Severity Guide, F-tags, Resident Rights, MDS Coding, Psychotropic Guidance, Quality Measures, Modified Abnormal Involuntary Movement Scale AIMs, Skilled Charting Guidelines, Alternatives to Restraint Use, Dementia Inservice. Abusive, Anger, Antidepressant, Anxiety, Conflict with Family, Decision-making, Depression, Disordered Thinking, Family Coping, Fear, Grief Over Lost Status, Hypnotic, Lithium, Manipulative Behaviors, MAO Inhibitor, Memory Problem, Non-compliance, Paranoia, Prefers Own Routine, Psychotropic Drug Use, Refuses to Eat, Rejects Care, Restraint, Room Change, Sensory Deprivation, Sensory Perception, Sleep Pattern Disturbance, Smoking, Social Isolation, Socially Inappropriate, Strengths, Terminal Prognosis, Trauma, Tricyclic, Unhappy with Roommate, Wandering, Withdrawal from Care.
- NEW! QSEN boxes provide you with the knowledge, skills, and attitudes necessary to continuously improve the quality and safety of care of the older adult. - NEW! Nurse Alert feature emphasizes important safety and health promotion content specific to the elderly patient. - NEW! Updated and expanded art program makes learning the material easier through clear and timely photographs and illustrations.