{"product_id":"chart-to-save-your-rn-license-a-comprehensive-guide-to-what-when-and-how-to-document-for-nurses-9798548570581","title":"Chart to Save Your RN License: A Comprehensive Guide to What, When, and How to Document for Nurses","description":"\u003cp\u003e\u003cb\u003eYou can be an excellent nurse in the clinical setting and still fail to \u003ci\u003eprove\u003c\/i\u003e that you are an excellent nurse if your documentation is inadequate.\u003c\/b\u003e \u003c\/p\u003e\u003cp\u003e\u003c\/p\u003eHaving 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. \u003ci\u003eIt 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.\u003c\/i\u003e \u003cb\u003eRather, 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.\u003c\/b\u003e\u003col\u003e\n\u003cli\u003e\n\u003cb\u003eThe Importance of Documentation \u0026amp; Overcoming Obstacles\u003c\/b\u003e\u003cul\u003e\n\u003cli\u003ePurpose(s) of Documentation\u003c\/li\u003e\n\u003cli\u003eDefensive Charting\u003c\/li\u003e\n\u003cli\u003eObstacles Impacting Quality of Medical Record\u003c\/li\u003e\n\u003cli\u003eOvercoming Obstacles\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c\/li\u003e\n\u003cli\u003e\n\u003cb\u003eLegal Responsibilities of the Nurse\u003c\/b\u003e\u003cul\u003e\n\u003cli\u003eDuties of the Nurse\u003c\/li\u003e\n\u003cli\u003eNurse Practice Acts\u003c\/li\u003e\n\u003cli\u003eDuties of the Hospital\u003c\/li\u003e\n\u003cli\u003eHospital Policy vs. State Board of Nursing Regulations\u003c\/li\u003e\n\u003cli\u003eReasonable Prudence\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c\/li\u003e\n\u003cli\u003e\n\u003cb\u003eFailure to Fulfill (Document) Responsibilities\u003c\/b\u003e\u003cul\u003e\n\u003cli\u003eFulfilling Responsibilities vs. Documenting Responsibilities\u003c\/li\u003e\n\u003cli\u003eWhat if Responsibilities Aren't Fulfilled?\u003c\/li\u003e\n\u003cli\u003eMistakes Happen\u003c\/li\u003e\n\u003cli\u003eProfessional Liability Insurance\u003c\/li\u003e\n\u003cli\u003eMalpractice\u003c\/li\u003e\n\u003cli\u003eMedical Negligence\u003c\/li\u003e\n\u003cli\u003eActing with Malice\u003c\/li\u003e\n\u003cli\u003eFraud\u003c\/li\u003e\n\u003cli\u003eWhat Happens When a Nurse is Charged with Malpractice?\u003c\/li\u003e\n\u003cli\u003eWhat to Do if You Receive Notification of a Claim\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c\/li\u003e\n\u003cli\u003e\n\u003cb\u003eCommon Charting Mistakes \u0026amp; How to Avoid Them\u003c\/b\u003e\u003cul\u003e\n\u003cli\u003eThe Most Common Errors\u003c\/li\u003e\n\u003cli\u003eCharting By Exception \u0026amp; Charting to Capture Minimal Data\u003c\/li\u003e\n\u003cli\u003e\"But I've Always Charted This Way, and Nothing Bad Has Happened Yet...\"\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c\/li\u003e\n\u003cli\u003e\n\u003cb\u003eWhat You Should Be Charting\u003c\/b\u003e\u003cul\u003e\n\u003cli\u003eHow and What to Chart\u003c\/li\u003e\n\u003cli\u003eQuick Glance Charting Checklists\u003c\/li\u003e\n\u003cli\u003eWhat is a Timely Manner?\u003c\/li\u003e\n\u003cli\u003eDocumenting Assessments\u003c\/li\u003e\n\u003cli\u003eSample Focused Assessment Criteria\u003c\/li\u003e\n\u003cli\u003eSharing the Responsibility\u003c\/li\u003e\n\u003cli\u003eModifying Electronic Data\u003c\/li\u003e\n\u003cli\u003eAbbreviations\u003c\/li\u003e\n\u003cli\u003eStanding Orders\u003c\/li\u003e\n\u003cli\u003eEarly Warning Systems Scores \u0026amp; Scales\u003c\/li\u003e\n\u003cli\u003eInformed Consent\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c\/li\u003e\n\u003cli\u003e\n\u003cb\u003eSpecial Circumstances\u003c\/b\u003e\u003cul\u003e\n\u003cli\u003ePaper Charting\u003c\/li\u003e\n\u003cli\u003eWriting an Incident Report\u003c\/li\u003e\n\u003cli\u003ePatient Leaving AMA\u003c\/li\u003e\n\u003cli\u003ePatient Threatening to Sue You\u003c\/li\u003e\n\u003cli\u003eIdentifying Patient Belongings\u003c\/li\u003e\n\u003cli\u003eAnother Member of the Team is Not Documenting Correctly\u003c\/li\u003e\n\u003cli\u003eRestraints\u003c\/li\u003e\n\u003cli\u003eDefective Equipment\u003c\/li\u003e\n\u003cli\u003eSuspected Abuse\u003c\/li\u003e\n\u003cli\u003ePatient Requesting to View Their EMR on Hospital Computer\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c\/li\u003e\n\u003cli\u003e\n\u003cb\u003eNarrative Notes\u003c\/b\u003e\u003cul\u003e\n\u003cli\u003eWhen \u0026amp; How to Write Notes\u003c\/li\u003e\n\u003cli\u003eOne Note or Several Notes?\u003c\/li\u003e\n\u003cli\u003eDaily Narrative Notes\u003c\/li\u003e\n\u003cli\u003eExamples of Common Notes Written As-Needed\u003c\/li\u003e\n\u003cli\u003eHow to Title Narrative Notes\u003c\/li\u003e\n\u003cli\u003eHow to Format Notes\u003c\/li\u003e\n\u003cli\u003eUsing Patient Names in Notes\u003c\/li\u003e\n\u003cli\u003eLength of Notes\u003c\/li\u003e\n\u003cli\u003eCreate a Template\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c\/li\u003e\n\u003cli\u003e\u003cb\u003eTips for Less Stress When Charting\u003c\/b\u003e\u003c\/li\u003e\n\u003cli\u003e\u003cb\u003eBONUS: How I Chart on a \"Typical\" Shift\u003c\/b\u003e\u003c\/li\u003e\n\u003c\/ol\u003e\u003cb\u003eABOUT THE AUTHOR\u003c\/b\u003e: \u003cbr\u003eI'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\u003cb\u003e\u003ci\u003e 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.\u003c\/i\u003e\u003cbr\u003e\u003c\/b\u003e","brand":"Independently Published","offers":[{"title":"Default Title","offer_id":50682705019154,"sku":"9798548570581","price":8.99,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0831\/4771\/8930\/files\/img_db908dc8-317f-49eb-a63e-061d2afdf4a8.jpg?v=1733971108","url":"https:\/\/surprise-castle.myshopify.com\/products\/chart-to-save-your-rn-license-a-comprehensive-guide-to-what-when-and-how-to-document-for-nurses-9798548570581","provider":"Surprise Castle","version":"1.0","type":"link"}