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.

Understanding documentation -- The nursing process -- Care plans -- Documentation systems -- Enhancing your documentation -- Avoiding legal pitfalls -- Documenting procedures -- Documenting special situations -- Acute care documentation -- Home health care documentation -- Long-term care documentation.