Author: Springhouse
Publisher: Lippincott Williams & Wilki
Keywords: documentation, nursing, guide, chartsmart, smart, chart
Number of Pages: 512
Published: 2006-01-01
List price: $45.95
ISBN-10: 1582559872
ISBN-13: 9781582559872

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 situatio