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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.

Advisory board

Contributors and consultants

Foreword

Documentation (in alphabetical order)

Appendices

• Computerized charting


• Abbreviations to avoid


• Common charting mistakes to avoid


• Charting checkup: You're on trial - How to protect yourself


• NANDA-I nursing diagnoses: Definitions and classifications


• Selected references



Index