Nursing Narrative Note Examples To Save Your License

Nursing Narrative Note Examples to Save Your License Book PDF/Epub Download

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!

Chart to Save Your RN License Book PDF/Epub Download

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.

Nursing Notes the Easy Way Book PDF/Epub Download

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.

Nursing Know how Book PDF/Epub Download

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.

IV Start Guide for Students New Nurses 5 Steps to Increase Competence Confidence Book PDF/Epub Download

In this book, you’ll find everything you need to know for successful intravenous access on a variety of patients, including in-depth explanations of common terminology and lingo common in the clinical setting, anecdotal stories, step-by-step outlines, in-depth narratives, guidelines to troubleshooting common problems associated with IV initiation, and more. 5 Steps to Mastery Between the front and back cover of this resource guide, there are five main concepts I’ll explain as if you were my student or orientee, having a conversation with me face-to-face. 1. Learn both the medical terminology and the slang. Knowing what the medical lingo means will help you absorb the most information from the anecdotes, and also sets you up for success to communicate in a professional manner in the clinical setting as a student or nurse. 2. Review the anecdotes where the IV insertion attempt is unsuccessful. This portion of the book mirrors the experience you would receive in a clinical setting if you were shadowing a nurse.Pay attention to what went wrong (explained after each anecdote) so that you know where to focus your attention when we discuss intravenous insertion in a more in-depth manner thereafter. 3. Learn about peripheral IV initiation, written as if I’m having a conversation with you face-to-face. There are plenty of textbook-style descriptions out there. I wrote in the same style I teach my students and orientees on a one-on-one basis so that you can read to retain, not just read to memorize. 4. Revisit the anecdotes and correct the problems that led to an unsuccessful IV initiation along with me. Troubleshooting along with me and thinking through how to manage certain scenarios differently to achieve a positive outcome will ingrain itself into your subconscious better than simply reading a textbook version of IV insertion, and will allow you to draw back on these hypothetical situations when you are faced with similar obstacles in the real world clinical setting. 5. Visualize your own success and apply it to the real world. When an endless supply of real people on whom to practice IV skills is not available, how do you start to build your skills? Reading this book with its conversational formatting will help you start to visualize patient care scenarios. Once you have established a mental skill set and the process is starting to become second nature, taking time to visualize an IV start from the beginning to the end will help you when you find yourself starting your first few dozen IVs in the clinical setting.

DocuNotes Book PDF/Epub Download

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.

Nursing Documentation Handbook Book PDF/Epub Download

This pocket-size guide saves nurses precious time while ensuring that a complete patient record is created and that legal, quality assurance, and reimbursement requirements are met. This handbook provides specific verbiage for charting patient progress, change or tasks accomplished for approximately 50 common problems. The new third edition has been completely updated to include Critical Assessment Findings, Subjective Findings for Documentation, Resources for Care and Practice, Legal Considerations, Time Saving Tips, and new Managed Care information. Plus, roughly 15 additional common problems and diagnoses have been added making this practical resource more valuable than ever. Diagnoses are in alphabetical order allowing for fast and easy access. Each patient problem or diagnosis found in this handbook includes specific documentation guidelines for the following aspects of nursing care: *Assessment of patient problem *Associated nursing diagnosis *Examples of objective findings for documentation *Examples of subjective findings for documentation *Examples of assessment of the data *Examples of potential medical problems for this patient *Examples of the documentation of potential nursing interventions/actions *Examples of the evaluations of the interventions/actions *Other services that may be indicated and their associated interventions and goals/outcomes *Nursing goals and outcomes *Potential discharge plans for this patient *Patient, family, caregiver educational needs *Resources for care and practice *Legal considerations for documentation, as appropriate Introductory chapters describe documentation, the medical record systems of nursing documentation, and current JCAHO and ANA standards related to documentation. Specialty sections provide important and specific guidelines for hospice care and maternal-child care. Appendices provide the latest NANDA-approved nursing diagnoses, descriptions of services provided by other disciplines, abbreviations, and a listing of resources (i.e., directory of resources, clinical newsletters and journals, Internet resources, further reading). Includes Time Saving Tips boxes to help minimize the time needed for documentation responsibilities. Each diagnosis includes a Critical Assessment Components/Findings section to help nurses with their critical decision making and determine whether an assessment finding indicates immediate attention or patient follow up. The Goals/Outcomes section of each diagnosis now appears at the beginning so that nurses know the intended goals and outcomes up front before beginning the assessment. All documentation guidelines now include sections on Examples of Subjective Findings for Documentation and Resources for Care and Practice. Includes Legal Considerations for Documentation as appropriate to highlight important legal issues. Part One has been updated to reflect the current managed care environment, including new information required by the National Community of Quality Assurance [NCQA], so that nurses can incorporate and focus on these changes as they document

Nursing Documentation Made Incredibly Easy Book PDF/Epub Download

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.

Nursing Documentation Book PDF/Epub Download

Focuses on the communicatiion skills that are the key to good documentation.

Chart Smart Book PDF/Epub Download

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

LPN Notes Book PDF/Epub Download

The 4th Edition of this popular, easy-to-use guide delivers the practical, clinically oriented content you need to deliver safe and effective health care in hospital and home settings. Thoroughly revised and updated, you’ll have access to even more of the commonly-used by rarely memorized clinical information that nurses and students need.

Chart Like A Pro Book PDF/Epub Download

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!

The OASIS Nursing Narrative Note RefeRNce Blueprint Book PDF/Epub Download

This is a book that specifies the aspects required of Medicare to be included within an OASIS nursing narrative note in order for a skilled nursing visit to be deemed as approved by, and reimbursable by Medicare.

First Year Nurse Book PDF/Epub Download

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!

Physical Assessment Check Off Notes Book PDF/Epub Download

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.

Clinical Case Studies for the Family Nurse Practitioner Book PDF/Epub Download

Clinical Case Studies for the Family Nurse Practitioneris a key resource for advanced practice nurses and graduatestudents seeking to test their skills in assessing, diagnosing, andmanaging cases in family and primary care. Composed of morethan 70 cases ranging from common to unique, the book compilesyears of experience from experts in the field. It is organizedchronologically, presenting cases from neonatal to geriatric carein a standard approach built on the SOAP format. Thisincludes differential diagnosis and a series of critical thinkingquestions ideal for self-assessment or classroom use.

The Nurses Book PDF/Epub Download

A New York Times bestseller. “A funny, intimate, and often jaw-dropping account of life behind the scenes.”—People Nurses is the compelling story of the year in the life of four nurses, and the drama, unsung heroism, and unique sisterhood of nursing—one of the world’s most important professions (nurses save lives every day), and one of the world’s most dangerous, filled with violence, trauma, and PTSD. In following four nurses, Alexandra Robbins creates sympathetic characters while diving deep into their world of controlled chaos. It’s a world of hazing—“nurses eat their young.” Sex—not exactly like on TV, but surprising just the same. Drug abuse—disproportionately a problem among the best and the brightest, and a constant temptation. And bullying—by peers, by patients, by hospital bureaucrats, and especially by doctors, an epidemic described as lurking in the “shadowy, dark corners of our profession.” The result is a page-turning, shocking look at our health-care system.

Strengthening Forensic Science in the United States Book PDF/Epub Download

Scores of talented and dedicated people serve the forensic science community, performing vitally important work. However, they are often constrained by lack of adequate resources, sound policies, and national support. It is clear that change and advancements, both systematic and scientific, are needed in a number of forensic science disciplines to ensure the reliability of work, establish enforceable standards, and promote best practices with consistent application. Strengthening Forensic Science in the United States: A Path Forward provides a detailed plan for addressing these needs and suggests the creation of a new government entity, the National Institute of Forensic Science, to establish and enforce standards within the forensic science community. The benefits of improving and regulating the forensic science disciplines are clear: assisting law enforcement officials, enhancing homeland security, and reducing the risk of wrongful conviction and exoneration. Strengthening Forensic Science in the United States gives a full account of what is needed to advance the forensic science disciplines, including upgrading of systems and organizational structures, better training, widespread adoption of uniform and enforceable best practices, and mandatory certification and accreditation programs. While this book provides an essential call-to-action for congress and policy makers, it also serves as a vital tool for law enforcement agencies, criminal prosecutors and attorneys, and forensic science educators.

The Future of Nursing Book PDF/Epub Download

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.

Pain Management and the Opioid Epidemic Book PDF/Epub Download

Drug overdose, driven largely by overdose related to the use of opioids, is now the leading cause of unintentional injury death in the United States. The ongoing opioid crisis lies at the intersection of two public health challenges: reducing the burden of suffering from pain and containing the rising toll of the harms that can arise from the use of opioid medications. Chronic pain and opioid use disorder both represent complex human conditions affecting millions of Americans and causing untold disability and loss of function. In the context of the growing opioid problem, the U.S. Food and Drug Administration (FDA) launched an Opioids Action Plan in early 2016. As part of this plan, the FDA asked the National Academies of Sciences, Engineering, and Medicine to convene a committee to update the state of the science on pain research, care, and education and to identify actions the FDA and others can take to respond to the opioid epidemic, with a particular focus on informing FDA's development of a formal method for incorporating individual and societal considerations into its risk-benefit framework for opioid approval and monitoring.

Mosby s Surefire Documentation Book PDF/Epub Download

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.