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Reference
ChartSmart:TheA-to-ZGuideto
BetterNursingDocumentation,ThirdEdition
LippincottWilliams&Wilkins
978-1-60547-764-0 •December2009 • Softbound •6” x9” •512pp. •41 Illus. •48Tables
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. LegalCasebook sidebars provide real-worldexamplesof
courtcases.AccuChartsampleformsshowhowtoaccuratelycomplete
various forms. Other highlights include expanded information on the
electronic medical record, current Joint Commission guidelines on
abbreviationuse, and thenewestNANDAnursingdiagnoses.
Features
•
NEW!
Additionof new, difficult, or timely charting situations
includingmoderate sedation,medication reconciliation, infant
identification, faxingmedical records, and requests by families for
medical advice.
•
NEW!
Current abbreviationuseguidelines fromThe Joint
Commission.
•
NEW!
Expanded informationonaccurately charting in the
electronicmedical record.
•
NEW!
NewestNANDAnursingdiagnoses includingdefinitions and
classifications.
•
NEW!
Updateof all entries to complywith current guidelines and
standards.
• A-to-Z format helps thenursefind topics in seconds.
• All populardocumentation systems covered.
• Nearly300documentation situations—more thanany competitor
—presented ina consistent format, each includingawritten
exampleor completed form.
•
AccuChart
Icons
.Accurately completeddocumentation forms and
directions.
•
LegalCasebook
. Sidebars provide real-worldexamplesof court
cases.
Table of Contents
AdvisoryBoard
ContributorsandConsultants
Foreword
Documentation (inalphabetical
order)
Appendices:
1: Computerized charting
2: Abbreviations to avoid
3: Common chartingmistakes to avoid
4: ChartingCheckup: You’re on trial—How
to protect yourself
5:NANDA-I nursing diagnoses:Definitions
andClassifications
6: SelectedReferences
Index