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Reference
Chart Smart: The A-to-Z Guide to
Better Nursing Documentation, Third Edition
Lippincott Williams &Wilkins
978-1-60547-764-0 • December 2009 • Softbound • 6” x 9” • 512 pp. • 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. Legal Casebook sidebars provide real-world examples of
court cases. AccuChart sample forms show how to accurately complete
various forms. Other highlights include expanded information on the
electronic medical record, current Joint Commission guidelines on
abbreviation use, and the newest NANDA nursing diagnoses.
Features
•
NEW!
Addition of new, difficult, or timely charting situations
including moderate sedation, medication reconciliation, infant
identification, faxing medical records, and requests by families for
medical advice.
•
NEW!
Current abbreviation use guidelines fromThe Joint
Commission.
•
NEW!
Expanded information on accurately charting in the
electronic medical record.
•
NEW!
Newest NANDA nursing diagnoses including definitions and
classifications.
•
NEW!
Update of all entries to comply with current guidelines and
standards.
• A-to-Z format helps the nurse find topics in seconds.
• All popular documentation systems covered.
• Nearly 300 documentation situations — more than any competitor
— presented in a consistent format, each including a written
example or completed form.
•
AccuChart
Icons
. Accurately completed documentation forms and
directions.
•
Legal Casebook
. Sidebars provide real-world examples of court
cases.
Table of Contents
Documentation (in alphabetical
order)
Appendices:
1: Computerized charting
2: Abbreviations to avoid
3: Common charting mistakes to avoid
4: Charting Checkup: You’re on trial — How
to protect yourself
5: NANDA-I nursing diagnoses: Definitions
and Classifications
6: Selected References