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CITATION

Keogh, James. Schaum's Outline of Medical Charting. US: McGraw-Hill, 2012.

Schaum's Outline of Medical Charting

Authors: James Keogh

Published:  July 2012

eISBN: 9780071736558 0071736557 | ISBN: 9780071736541
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  • Contents
  • Chapter 1 Charting Basics
  • 1.1 Definition
  • 1.2 The Chart Is a Central Reference
  • 1.3 Types of Charts
  • 1.4 Components of a Chart
  • 1.5 Writing in a Chart
  • 1.6 Rules for Charting
  • 1.7 Rules for Verbal Orders
  • 1.8 What to Write
  • 1.9 Fixing Errors
  • Chapter 2 Charting Legalities
  • 2.1 Definition
  • 2.2 A Patient’s Legal Medical Record
  • 2.3 Limit Legal Liability
  • 2.4 An Incident Report
  • 2.5 Other Legal Documents
  • 2.6 Patient Elopement
  • 2.7 Charting and Patient Rights
  • Chapter 3 Charting Medication and Routine
  • 3.1 Definition
  • 3.2 The Medication Administration Record (MAR)
  • 3.3 The Kardex
  • 3.4 Taking Off Orders
  • 3.5 Avoid Common Errors When Using MAR and Kardex
  • 3.6 Charting Narcotics
  • 3.7 IV: Administration
  • 3.8 Intake and Output Flow Chart
  • 3.9 Transferring a Patient
  • Chapter 4 Patient Care Plans
  • 4.1 Definition
  • 4.2 Care Plan Objective
  • 4.3 Categories of Nursing Diagnosis
  • 4.4 Care Plan Formats
  • Chapter 5 The Words of Charting
  • 5.1 Definition
  • 5.2 Charting Your Assessment
  • Chapter 6 Computer Charting
  • 6.1 Definition
  • 6.2 Computer Charting System Components
  • 6.3 Workstation: An Inside Look
  • 6.4 Network: An Inside Look
  • 6.5 Database: An Inside Look
  • 6.6 A Tour of the IT Department
  • Chapter 7 Charting Software
  • 7.1 Definition
  • 7.2 Different Charting Software
  • 7.3 Getting Started
  • 7.4 The Chart Begins
  • 7.5 Locating a Patient’s Chart
  • 7.6 Displaying the Patient’s Chart
  • Chapter 8 Basic Electronic Charting
  • 8.1 Definition
  • 8.2 To-Do List
  • 8.3 Vital Signs
  • 8.4 Comments
  • 8.5 Charting I&O
  • 8.6 Reviewing the Entry
  • 8.7 Patient Profile
  • 8.8 Care Plans
  • Chapter 9 Entering Patient Assessments in Charting Software
  • 9.1 Charting an Assessment
  • 9.2 Entering an Assessment
  • 9.3 Streamlining Documentation
  • 9.4 Customize the Assessment
  • 9.5 Something Unusual
  • 9.6 Saving and Reviewing
  • Chapter 10 Entering Medication Administration in Charting Software
  • 10.1 Definition
  • 10.2 Enforcing Rights of Medication Administration
  • 10.3 Medication Administration Workflow
  • 10.4 Documenting Medication Administration
  • 10.5 Recovering when Problems Occur
  • Chapter 11 Entering Orders
  • 11.1 Define Order
  • 11.2 Entering an Electronic Order
  • 11.3 Compound Medical Order
  • 11.4 Computerized Physician Order Entry
  • 11.5 Dietary Orders
  • 11.6 Orders Inquiry and Changing Orders
  • 11.7 Response to Orders
  • 11.8 Telephone Orders
  • Chapter 12 Private Practice and Clinics
  • 12.1 Private Practice
  • 12.2 Private Practices and Expenses
  • 12.3 Private Practice and Record Keeping
  • 12.4 Private Practice and Electronic Medical Record Keeping
  • 12.5 Electronic Medical Record Keeping Incentive
  • 12.6 Ownership of Electronic Medical Record
  • 12.7 Exchanging Electronic Medical Records
  • 12.8 Private Practice Scheduling
  • 12.9 The Dashboard
  • 12.10 The Patient’s Chart
  • 12.11 Test Results Online
  • 12.12 Challenges of Test Results Online
  • 12.13 Electronic Prescriptions
  • 12.14 Tailoring the Software and Staff Training
  • Index