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

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 Casebooks provide examples of legal implications of documentation. AccuChart sample forms show how to accurately complete various forms. Thoroughly updated to reflect current practice, this Second Edition 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.Lippincott Williams and Wilkins Staff is the author of 'Chart Smart The A-to-Z Guide to Better Nursing Documentation', published 2006 under ISBN 9781582559872 and ISBN 1582559872.