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.
Auflage
Sprache
Verlagsort
Zielgruppe
Produkt-Hinweis
Maße
Höhe: 229 mm
Breite: 152 mm
Gewicht
ISBN-13
978-1-60547-764-0 (9781605477640)
Copyright in bibliographic data and cover images is held by Nielsen Book Services Limited or by the publishers or by their respective licensors: all rights reserved.
Schweitzer Klassifikation
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
