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CITATION

Richards, Joan and Keogh, James. Medical Charting Demystified. US: McGraw-Hill Professional, 2008.

Medical Charting Demystified

Authors: Joan Richards and James Keogh

Published:  July 2008

eISBN: 9780071643504 0071643508 | ISBN: 9780071498487
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  • Contents
  • Acknowledgment
  • Chapter 1 Charting Basics
  • A Patient’s Record
  • Types of Charts
  • Writing in a Chart
  • What to Write
  • Fixing Errors
  • Summary
  • Quiz
  • Chapter 2 The Legal Aspect of Charting
  • A Patient’s Record and the Law
  • HIPAA
  • Charting to Limit Legal Liability
  • Elements of Malpractice
  • Writing an Incident Report
  • Other Legal Documents Part of the Patient’s Chart
  • Summary
  • Quiz
  • Chapter 3 Charting Medication and Normal Routines
  • The MAR
  • The KARDEX
  • Taking Off Orders
  • Avoid Common Errors When Using the MAR and KARDEX
  • Charting Narcotics
  • IV Administration
  • Intake and Output Flow Chart
  • Transferring a Patient
  • Summary
  • Quiz
  • Chapter 4 Patient Care Plans
  • Purpose of a Care Plan
  • Categories of Nursing Diagnosis
  • Care Plan Formats
  • Summary
  • Quiz
  • Chapter 5 Acute Care Charting
  • Writing in the Chart
  • Summary
  • Quiz
  • Chapter 6 Computer Charting
  • Parts of the Computer Charting System
  • Workstation: An Inside Look
  • Network: An Inside Look
  • Demystifying Wifi Transmission
  • Database: An Inside Look
  • A Tour of the IT Department
  • Summary
  • Quiz
  • Chapter 7 Charting Software
  • Why Is There Different Charting Software?
  • Jumping In
  • Summary
  • Quiz
  • Chapter 8 To-Do List, Vital Signs, and I&O Charting
  • To-Do List
  • Vital Signs
  • Charting I&O
  • Reviewing Your Entry
  • Summary
  • Quiz
  • Chapter 9 Entering Patient Assessment in Charting Software
  • Charting an Assessment
  • Summary
  • Quiz
  • Chapter 10 Entering Medication Administration Charting Software
  • Enforcing the Five Rights of Medication Administration
  • The Work flow
  • Using Charting Software to Document Medication Administration
  • Recovering When Things Go Wrong
  • Summary
  • Quiz
  • Chapter 11 Entering Orders in Charting Software
  • An Order
  • Entering the Order
  • Compound Order
  • Summary
  • Quiz
  • Final Exam
  • Answers to Quizzes
  • Answers to Final Exam
  • Index