Chart Smart: The A-to-Z Guide to Better Nursing Documentation

Chart Smart: The A-to-Z Guide to Better Nursing Documentation Author Lippincott Williams & Wilkins
ISBN-10 1605477648
ISBN-13 9781605477640
Year 2009-12-24
Pages 512
Language English
Publisher LWW
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Thoroughly updated for its Third Edition this portable handbook shows nurses in all practice settings exactly what to document in any situation Nearly 300 alphabetically organized entries cover diseases emergencies procedures legal and ethical problems and difficult situations involving patients families and other health care professionals Legal Casebook sidebars provide real world examples of court cases AccuChart sample forms show how to accurately complete various forms This edition includes new difficult and timely charting situations such as moderate sedation medication reconciliation infant identification faxing medical records and requests by families for medical advice Other highlights include expanded information on the electronic medical record current Joint Commission guidelines on abbreviation use and the newest NANDA nursing diagnoses

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