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
• difficult situations involving patients, families, and other health care professionals

Legal Casebooks provide examples of legal implications of documentation. AccuChart sample forms show how to accurately complete various forms.

Thoroughly updated to reflect current practice, Chart Smart, Second Edition also provides information on the electronic health record. New entries cover situations such as surgical site verification, patient glucose self-testing, cultural needs identification, HIPAA, and reporting critical test values. A new appendix covers prohibited abbreviations.

Contents

Documentation

Appendices

• Documentation systems
• Electronic health record
• JCAHO National Patient Safety Goals
• Abbreviations to avoid
• NANDA nursing diagnoses

Index

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ORDER NOW Chart Smart The A-Z Guide to Better Nursing Documentation Second edition 2007 (available now) • 497 pages • $44.95 + shipping Texas residents please add 6.75 % sales tax