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Now in its third edition, ChartSmart: A-to-Z Guide to Better Nursing Documentation is completely updated with hundreds of practical examples that explain and show you, at a glance, how to chart safely and responsibly in all clinical settings--hospitals, outpatient and rehabilitation centers, long-term care facilities, even right in the patient's home. Learn how to document routing nursing care as well as essential details you need to record for emergencies, complex procedure, and difficult situations involving patients, families, and other health care team members.
Key Features:
- Nearly 300 alphabetically arranged entries, all thoroughly revised to comply with the latest nursing, medical, and government standards
- Scores of completely filled-in sample forms--admission assessments, patient medical records, flow sheets, progress notes, care plans, patient teaching sheets, risk assessment scales, medication and adverse reaction charts, refusal of treatment forms
- Detailed nurse's notes depicting practical, real-life clinical scenarios
- Legal issues--how to document to protect yourself against lawsuits, HIPAA regulations and confidentiality, writing an incident report
- Coverage of the most popular documentation systems
New to this Edition:
- New entries on charting moderate sedation, medication reconciliation, infant identification, faxing medical records, and family requests for medical advice
- Expanded section on charting in the electronic medical record
- Newest NANDA nursing diagnoses with complete definitions and classifications
- The Joint Commission's current guidelines on use of abbreviations
