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254165724
The Charting Protocols Bible for Nurses & NPs: The Complete Step-by-Step Guide to Court-Ready Documentation. 80 Protocols, Specialty Playbooks, and
Preces #:
254165724
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- A shift lasts twelve hours. The chart lasts forever. Every nurse has heard if it was not charted, it was not done. Almost no nurse was ever taught how to chart so that the record proves the care. The Charting Protocols Bible turns nursing documentation into what you already trust on every unit: a numbered protocol, the same every time, so nothing is left to memory on a bad night.Written for nurses and nurse practitioners at every level, it shows exactly how auditors, Boards of Nursing, and attorneys read a chart, and how to write one that leaves them nothing to question. Inside this 198-page guide:80 one-page protocols in 10 zones: admission, change in condition, medications, pain, wounds and devices, falls and restraints, consent and refusal, communication, transitions, and end of life. Each protocol gives the must-document elements, the step-by-step order, the phrases never to write, and the same event written as a weak note and a strong note.12 specialty playbooks: Med-Surg, ICU, Emergency, Perioperative, Obstetrics, Pediatrics, Psychiatric, Long-Term Care, Home Health, Hospice, Telehealth, and School and Occupational Health.A full chapter for nurse practitioners: medical decision making and time, the structure of a defensible visit note, prescribing and controlled substances, closed loops, telehealth and billing rules, and four note templates.The foundations: the seven elements of a defensible note, every format from SOAP to charting by exception, the language rules, late entries and corrections, and the EHR audit trail.What happens after: incident reports, chart review, depositions, Board investigations, employer investigations, plus a preceptor guide and a 30-day habit plan.Reference tools: an A-Z situation directory, 200+ weak-to-strong phrases, abbreviation lists, a master chart of all 80 protocols, 8 cheat sheets, 3 brain sheets, and a workbook. Honest, supportive, and safeEvery example is fictional and every timing rule is typical practice to be checked against your own facility policy. The book never asks you to write more; it asks you to write what happened, in order, with times, and to close every loop you open. Nothing here is legal or clinical advice.Ideal for nursing students, new graduates, RNs and LPNs, travel nurses, nurse practitioners, charge nurses, preceptors, and educators. Chart the care you actually gave, and let the record speak for you.
| Publisher | Vania Snee |
| Publication date | 6 Sept. 2026 |
| Language | English |
| Print length | 198 pages |
| ISBN-10 | 180335948X |
| ISBN-13 | 978-1803359489 |
| Item weight | 585 g |
| Dimensions | 21.59 x 1.14 x 27.94 cm |
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